Ingenix InSite User Group

May 11, 2010

Approval Code: IN154

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Ingenix InSite User Group: Welcome

Administrative Reminders: This call is hosted in a listen only mode for participants until our Q&A

segment. Questions you may want to ask prior to the Q&A segment can be typed in

our chat panel for the host to address Please keep your phones on mute during Q&A.

The webex login password for this call is ‘insite’. When logging into the webex please enter in your first and last name. The user group presentation materials will be sent with the meeting minutes. Ingenix InSite User Group Questions or Product Enhancement requests?

Email ingenix.insite@ingenix.com. Ingenix InSite Website Questions? Call or email the Ingenix Helpdesk 1-866-

818-7503 or client.support@ingenix.com.

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Ingenix InSite User Group: Agenda

10:00 AM – 10:05 AM Welcome & InSite Operations Announcements 10:05 AM – 10:20 AM RAF Calculator and RAF Build-up 10:20 AM – 10:40 AM TIA, Stroke & Late Effects of Stroke 10:40 AM – 10:50 AM InSite Custom List for Printing Multiple PAF’s Demo 10:50 AM – 11:00 AM Q & A

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InSite Operations Announcements

Data Refresh Update– InSite data was refreshed May 8th

– Shifted years on the following reports– Group and Provider Summary (PY 2010, PY 2011)– Summary of Accepted HCCs/Dx (PY 2009, PY 2010, PY 2011) also shifting in the member view– Members without HCCS (PY 2010, PY 2011)– HCC RAF Detail (PY 2009, PY 2010, PY 2011) also shifting in the member view– PCP RAF Report (2009 DOS, 2010 DOS)– Largest Declining RAF Quickview (2009 DOS, 2010 DOS)– Prevalence Report (Relative HCC Factor Current Yr PY 2011, Prior Yr PY 2010 AND Prevalence Rate

Current Yr DOS 2010, Prior Yr DOS 2009)– Patient Management (RAF calculation to be based on 2009 DOS)

– Next data refresh targeting June 5th

Upcoming Release– Next InSite Release targeting May 28th – Includes new security features, new report, and new InSite help features– Separate training scheduled to review new release functionality

Build-up RAF and RAF Calculator

Presented by:Ian MoxleyAnalytics

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CMS RAF– CMS calculates the RAF based on a specific data collection period and

is reflected in the MMR and MOR.• Data collection periods corresponds to dates of service and moves forward

every six months based on the CMS sweeps.

MMR (Monthly Membership Report)– Provides member-level information to reconcile payment from CMS– Flags and Indicators– Payment and adjustment information

MOR (Model Output Report)– Supplements the MMR by identifying specific information used in making

risk adjustment calculations– Age/Sex– Medicaid and Originally Disabled– HCC disease groups– Disease Interactions

RAF Types - CMS

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Build-up RAF– RAF based on Claims/Encounters/MOR

• Members who have been with the health plan for less than six months, the RAF is calculated from the MOR.

• Members who have been with the health plan for more than six months, the RAF is built-up and calculated from CMS qualifying claims and encounter data.

– The “Final” that would be in period 9 is not needed because it would exactly match the “Adjusted” period 8 until the report shifts years in March/April. After the Shift, the data for that period is reflected in period 6.

RAF Types – Build-up

PY 2009 Payment Year 2010 Payment Year 2011 Payment Year

Period 1 2 3 4 5 6 7 8

RAF Prelim Adjusted Final Prelim Adjusted Final Prelim Adjusted

Sweep Closed with Sept 2008

Sweep

Closed with March 2009

Sweep

Closed with Jan 2010 Sweep

Closed with Sept 2009

Sweep

Closed with March 2010

Sweep

Will build until Jan

2011 Sweep

Will build until Sept

2010 Sweep

Will build until March 2011 Sweep

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HCC RAF Detail Report Example

Example of InSite Report with Build-up RAF

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All InSite Reports impacted by Build-up RAF– HCC RAF Detail – PCP RAF– Largest Declining RAF Quickview– Patient Management

InSite Report(s) with Build-up RAF

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Learning and Resources Deep Dive Review – Part 3

- Overview

Learning and Resources Tab – Utilities and Tools

• RAF Calculator

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Purpose of this utility– User-driven tool to help dynamically calculate a RAF score– Scores are calculated for a single member at a time

Components– Instructions: Guidance on use and functionality of tool– Calculator: Input screen to enter member and diagnosis information– Output: RAF score summary and payment calculation

Technical Details– Excel based application– Select “Enable Macros”

when the file initially opens

RAF Calculator

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Step 1: Enter Member Information

RAF Calculator

Key Points• Enter information into YELLOW cells only• “Payment Year” can be from 2008-2011 (dates of

service 2007-2010)- RAF adjustments (FFS Normalization & Coding

Intensity) determined based on payment year• Age: Determined as of February of payment year

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Step 2: Enter Special Status & Location

RAF Calculator

Key Points• Special Status:- Disabled: Y or N- Original Eligibility: Aged or Disabled- Community or Institutional

• County Rate determined based on payment year

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RAF Calculator

Step 3: Enter Diagnosis Information (HCCs)

Key Points• Maximum of 16 HCCs can be entered• HCC Factors are based on identified payment year• Disabled & Disease Interactions are listed in

shaded grey section (circled in blue)

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RAF Calculator

Key Points• If HCCs within the same hierarchy are

entered, they will be highlighted in red with a message to remove one of the duplicate lines

• In the example above, either HCC 19 (Diabetes without Complications) or HCC 17 (Diabetes with Acute Complications) should be removed because they fall within the same HCC hierarchy

Step 3: Enter Diagnosis Information (HCCs)Error Handling: HCC Hierarchy

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RAF Calculator

Step 3: Enter Diagnosis Information (HCCs)Error Handling: Duplicate HCCs

Key Points• If duplicate HCCs are entered (HCC 80 in the

example above), they will be highlighted in red with a message to remove one of the duplicate lines

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Results: Calculator Sheet

RAF Calculator

A

B

C

Key Points• Results will display immediately as inputs are entered• Total RAF is displayed as: Subtotal of Age/Sex + Special Status +

HCCs, Total RAF after Adjustments, Estimated Annual Revenue for Payment Year

A B

C

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Results: Output

RAF Calculator

Key Points• Total RAF components and

calculation are shown again

• Interactions are displayed as subtotal

• Estimated payment is provided: • Estimated PMPM = Average

County Rate x Total RAF (after adjustments)

• Estimated PMPY = PMPM x 12 months

TIA, Stroke & Late Effects of Stroke

Presented by

Mary Jo Groome, CPC-H, CCS-PSr. Provider Training & Development ConsultantIngenix, Clinical Assessment Solutions

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Coding Disclaimer

This training and information presented is for informational purposes only and does not replace the professional judgment and expertise of the individual performing coding based on numerous factors including, but not limited to, documentation in the medical record and other industry recognized coding guidance. Because codes, coding requirements and standards can and do change, the individual assigning codes is reminded to verify the accuracy, specificity, currency and acceptability of such codes and coding methods used.

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TIA, Stroke and Late Effects of Stroke

Simply Stated:

When did the event occur?

What deficits were left after the event that are evident today?

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ICD-9-CM Official Guidelines for Coding and Reporting

The tense matters to documentation and coding:

–Diagnosis codes have been submitted for acute conditions when the beneficiary was status post

–Or, had a history of the condition

Be cautious with the use of the following terms: – Acute

– Status post

– History of

– Impending

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Transient Ischemic Attack

(TIA)

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TIA – Transient Ischemic Attack

Look-up in ICD-9-CM:

– Attack• Transient ischemic (TIA) 435.9

Tabular of ICD-9-CM:

– 435.9 Unspecified transient cerebral ischemia• Impending cerebrovascular accident• Intermittent cerebral ischemia• Transient ischemic attack (TIA)

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TIA – Transient Ischemic Attack

Category 435

– Includes:• Cerebrovascular insufficiency (acute) with transient focal

neurological signs and symptoms• Insufficiency of basilar, carotid, and vertebral arteries• Spasm of cerebral arteries

– Excludes:• Acute cerebrovascular insufficiency NOS (437.1)• That due to any condition classifiable to 433 (433.0-433.9)

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Stroke & Late Effects of

Stroke

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Stroke: Common Coding Error

When did the event occur?

One of the most common coding errors seen in chart review

is the assignment of a stroke code in the present tense

when the coder is actually trying to code for the residual

conditions left behind by a prior stroke.

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Documentation of Stroke

When Did The Event Occur?

Document Acute Stroke on first admission to the

hospital only. (434.91)

Document Residual Deficits of Stroke on office

visits following the acute incident. (438.XX) (Late Effects)

Document History of CVA if there are no residual

deficits from a prior stroke code. (V12.54)

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Documentation of Stroke

Diagnostic statements need to be specific regarding site or type of CVA.

Concise documentation will lead to specified code selection.– Example:

CVA due to cerebral embolism with infarction(434.11)

Cerebral artery occlusion (434.9x)

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Documentation of Late Effects of Stroke

A late effect is the residual condition that remains after recovery of the acute phase.

Document deficits after discharge from the initial acute episode.

Example:

Aphasia due to CVA 6 months ago (438.11)CVA two years ago with residual hemiplegia

(438.20)

There is no time limit for the reporting of a residual.

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Late Effects Coding: More than just for Stroke

The Coding of “Late Effects”

More than just for Stroke

“Late Effect” coding generally requires two codes. One for the

residual and one for the resolved condition.

Example:

Moderate Mental Retardation due to previous poliomyelitis.Code: 318.0 - Retardation, Mental, ModerateCode: 138 - “Late Effects” – poliomyelitis

Normally, this is a two code scenario

Stroke is the exception.

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Late Effects: The Index

Late - see also condition– effect(s) (of) - see also condition

• cerebrovascular disease (conditions classifiable to 430-437) 438.9• With

– alterations of sensations 438.6– aphasia 438.11– apraxia 438.81– ataxia 438.84– cognitive deficits 438.0– disturbances of vision 438.7– dysarthria 438.13– dysphagia 438.82– dysphasia 438.12– facial droop 438.83– facial weakness 438.83– fluency disorder 438.14

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Late Effects: The Index

– Late Effects, cerebrovascular disease, with:• hemiplegia/hemiparesis

– affecting» dominant side 438.21» nondomiant side 438.22» unspecified side 438.20

• monoplegia of lower limb– affecting

» dominant side 438.41» nondominant side 438.42» unspecified side 438.40

• monoplegia of upper limb– affecting

» dominant side 438.31» nondominant side 438.32» unspecified side 438.30

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Late Effects: The Index

– Late Effects, cerebrovascular disease, with:

• paralytic syndrome NEC– affecting

» bilateral 438.53» dominant side 438.51» nondominant side 438.52» unspecified side 438.50

• speech and language deficit 438.10• specified type NEC 438.19• stuttering 438.14• vertigo 438.85• specified type NEC 438.89

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Coding Late Effects of Stroke

Example:

Cerebrovascular accident two years ago with residual hemiplegia

Code: 438.20 “Index” - Late Effects,

Cerebrovascular Disease,

with Hemiplegia,

Unspecified Side

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Coding Stroke & Late Effects of Stroke

Acute embolic CVA with infarction; previous CVA with residual dysphagia.

– 434.11 – Infarction, cerebral, embolic– 438.82 – Late effect(s), cerebrovascular disease, with

dysphagia

Aphasia due to Cerebrovascular Accident 6 months ago.

– 438.11 - Late effect(s), cerebrovascular disease, with aphasia

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Late Effects: The Index

Documentation states: Patient has left sided weakness due to previous CVA two years ago”.

See> Late effects, cerebrovascular disease>specified type NEC

Under 438.89 Other late effects of cerebrovascular diseaseUse additional code to identify the late effect

TIP: Assign 438.89 and 728.87 muscle weakness, for residual weakness secondary to late effect of

CVA.

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Category 438

Late effects of cerebrovascular disease– Excludes:

• Personal history of:– Cerebral infarction without residual deficits

(V12.54)– PRIND (Prolonged reversible ischemic

neurologic deficit) (V12.54)– RIND (Reversible ischemic neurological

deficit) (V12.54)– Transient ischemic attack (TIA) (V12.54)

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History of TIA & Stroke

When a provider documents “History of TIA” or “History of Stroke”

– Code V12.54• Personal history of

– Transient ischemic attack (TIA) , and cerebral infarction without residual deficits

When a provider documents a history of stroke with residual deficits

– Code from the Late Effects category 438• Late effects of cerebrovascular disease

– Specific to the documented residual

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Question about Stroke Syndrome

How would you code if the provider documented “stroke syndrome” or “little stroke syndrome”?

– If you look in the Index under Syndrome, you will find:• Stroke (see also Disease, cerebrovascular, acute) 436

– Little 435.9– If you look in the Index under Disease, cerebrovascular, you will

find:• Acute 436

– Embolic – see Embolism, brain– Late effect – see Late effect(s) (of) cerebrovascular

disease– Puerperal, postpartum, childbirth 674.0x– Thrombotic – see Thrombosis, brain

“Stroke syndrome” is coded as 436; “little stroke syndrome” is coded as 435.9

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A Final Word about 436

436 – Acute, but ill-defined, cerebrovascular diseaseApoplexy, apoplectic:

NOSattackcerebralseizure

Cerebral seizure

TIP: Do not assign when documentation indicates “CVA, stroke, or cerebral infarction.” See instead default code 434.91.

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Ingenix / Team members would like to …

Thank You

Questions will be taken later

InSite Custom List for Printing Multiple Patient Assessment Forms (PAFs) Demonstration

Presented by:Francesca SicilianoInSite Product Business Analyst

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Overview of Downloading Multiple PAFs

Multiple PAF Download (By Criteria)– New functionality in InSite as of 3/31/2010– Suggested Uses

1. Identify the patients to be seen for a day, add those member’s PAFs to the custom list, and download all the PCP’s PAFs at once

2. Identify all the members without office visits that are newly enrolled to a plan, add to custom list, and download all the PAFs at once

– Functionality Highlights1. Users have the ability to select member records from any report2. User can add selected records to the custom list 3. User can add all records on the report to the custom list4. User will go to the Custom List Tab to export records (100 records can be

downloaded at one time) – Can export PAF, PAF with Problem List or Problem List alone

5. User can delete the entire list or individual records if they decide to NOT export

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March 2010 InSite Release

Multiple PAF Download (By Criteria)1. User will have the ability to select member records from any

report

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March 2010 InSite Release

Multiple PAF Download (By Criteria)2. User can add selected records to the custom list (note: User must add them to the custom list before moving to the next page)

Check box to select member record

Click Add to Custom List

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March 2010 InSite Release

Multiple PAF Download (By Criteria)3. User can add all records on the report to the custom list

Click Add ALL to Custom List to add all records on the report to the custom list

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March 2010 InSite Release

Multiple PAF Download (By Criteria)4. User will go to the Custom List Tab to export records (50 or

more records can be downloaded at one time – final # of records to be determined) – Can export PAF, PAF with Problem List or Problem List

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March 2010 InSite Release

Multiple PAF Download (By Criteria)5. User can delete entire list or individual records the decide to

NOT export

To remove an individual record from this list

To Remove the Entire List

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User Group Feedback Discussion

Best Practices Agenda Item

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Question and Answer

Approved: IN071