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Clinical Documentation Improvement

Clinical Documentation Improvement


Welcome to the Results and Recognition Quality Programs of 2021. This webinar will discuss the importance of clinical documentation, a review of compliant versus non-compliant clinical documentation, and what should be included when submitting supplemental data and how to submit supplemental data.

The objectives for this webinar are to: Understand HEDIS and the goal of the Quality Programs, Review importance of clinical documentation, Identify compliance by improving clinical documentation, and Understand methods to send documentation securely.

So what is HEDIS? HEDIS stands for Healthcare Effectiveness Data and Information Set. HEDIS was developed by the National Committee of Quality Assurance, or NCQA, and is a set of standardized performance measures designed to ensure that the public has the information it needs to compare organization performances. HEDIS is not exclusive to Horizon. 90% of the country’s health plans use HEDIS to measure performance on many different dimensions of care & service. HEDIS has 91 measures in total consisting of adult & pediatric measures. For the Quality Programs, we focus and incentivize on a selected few.

Our goal is to improve clinical outcomes and performance on HEDIS measures and promote the care received by our members.

Let’s look at some key factors as to why the Quality Programs are so important. The primary goal is to maintain and improve the health and quality of care received by our members. The program help to improve clinical outcomes performance on HEDIS measures. It provides a variety of opportunities that lead to better care and improved health outcomes for our members. The Quality providers are offered best practices for preventative screenings, immunizations and treatment of chronic conditions. The programs also show providers how to optimize captured data to reflect quality improvement outcomes. Providers in the Quality Program have a dedicated Clinical Quality Improvement Liaison. This CQIL will assist with practice transformation and can lead to improved clinical documentation. As we move along in this WebEx, you will hear the term “Measurement year.” This refers to the year in which we are collecting data from. The measurement year starts January 1st and ends December 31st

So why is clinical documentation so important? It provides a valuable account of patient’s concerns described to the provider, including any medical history. It allows physicians and other health care professionals to evaluate a patient’s needs and evaluate if the treatment plan is being effective. Documentation is a great communication tool to help improved the continuity of care among providers and other health care professionals involved in the patient’s care. Documentation serves as a legal document to verify care rendered and the date of the service. Clinical documentation may also be useful for research and education. Documentation also plays an important role in data collection and reporting for HEDIS. Please remember, documentation is everything and as the saying goes, if it’s not documented it’s not done.

If for any reason there is an audit conducted, documentation in the medical record must support the codes submitted on the claim. There are 3 important reasons why documentation is important for claims: It facilitates accurate and timely claims review and payment - It minimizes many of the challenges related to claims processing and HEDIS chart requests, and - It supports the HEDIS codes reported on billing statements. When reviewing medical records to close gaps in care for supplemental data, the documentation needs to support the measure. For example, if the provider is submitting a medical record for closing a gap of care for Controlling High Blood Pressure, the last visit in the measurement year needs to have a blood pressure documented. Some advantages of an Electronic Medical Record: EMR templates help providers integrate all the necessary components for proper clinical documentation in a very clear & structured manner - An EMR can assist providers in addressing specific areas for documentation purposes - A properly designed and implemented EMR system can actually prefill portions of a template needed to avoid errors in the patient’s medical record - It can also collect essential HEDIS data, alert providers to non-compliant patients and show what, if any preventive services are needed at the time of the visit. Another advantage of utilizing an EMR is that medical records can be more easily read and are less prone to have errors go unnoticed.

A lot of the clinical documentation we refer to includes the submission of supplemental data or EHR data feeds. Keep in mind the most accurate way to close gaps of care when services are rendered is with correct coding. Supplemental data can be submitted year-round. Supplemental information refers to additional clinical data about a member, beyond the administrative claims, used for calculating HEDIS measures. Non-standard supplemental data or the medical record submission, must be signed and dated by a treating Physician, Nurse Practitioner or Physician Assistant. All dates must include a month, day and year. To be compliant, please provide only the necessary documentation required to close the gap in care. This should include: name of the patient, date of birth, date of the service, clear documentation of the services rendered to close the gap.

Some requirements to remember if you are submitting supplement data: Data Source - information from the member’s medical record from the same site. The reference of "same data source" refers to the type and location of the data. All the information should be in one location, contained in one medical record. For example, if the member is seeing a specialist, the consult notes should be in the medical record at the PCP’s office, this would be considered that same data source. Minimum Necessary - submit only what is medically necessary to complete the review. Please do not send us the entire medical record, only the documentation needed to close the gap in care. Again for example, if you are submitting documentation for Controlling High Blood Pressure, you should only send the last visit in the measurement with a documented blood pressure. The pages must include members’ date of birth, name, date of service and provider’s signature. If for any reason the member’s date of birth is not noted on the pages, you will also need to send in the patient’s demographic sheet. Supplemental Data Labs – some measures requires results, reported data or collected date. For example for A1C testing, lead & cervical cancer screening, we need the reported date and results. For Breast cancer screening and colorectal screening, we would need to have the collected data for the date it was performed. Exceptions - A vital sign sheet is acceptable; please remember it still needs to have the member’s name, and date of birth on it. Snippets are not acceptable because they have to show all of the documentation and they only show a small part of it. BUT, an entire screen shot of the EMR with all the information was captured and is easily identified, may be acceptable. So again, just to re-cap, vital Sign sheets are acceptable, snippets are not acceptable, and screen shots the EMR must be identified and the entire screen captured to be considered acceptable.

Some common reasons as to why documentation may be non-compliant: Missing or incomplete required documentation components; for example, for Cervical Cancer Screening under Medical History it’s documented the member had a cervical cytology in January of 2021 but results were not noted. Incomplete services rendered; an example, Tdap was given but there was no Meningococcal given for the Combo 1. Another reason for non-compliance would be if the service was provided outside the required time frame; for example, lead screening must be done on or before a child’s 2nd birthday; many of the HEDIS measures need to be completed within a specific time or age frame If the provider signature, the date of service, and/or the unique member identification is missing, such as DOB, these would make the documentation non-compliant; please remember if using an EMR, the electronic signature is acceptable. Claims/encounter and/or codes not submitted for services rendered; when performing a service and/or treatment, it may be a good idea to refer to the Provider HEDIS Tips Booklet; If you do not have a copy, please reach out to your CQIL; this tips booklet has the NCQA’s suggested billing codes to help guide you on coding for certain services to ensure the gap are closed through claims administratively; please remember, we cannot and will not tell you how or what to code, any codes submitted must reflective in the services and treatments rendered and clearly documented in the medical record. Next we’re going to look at some chart examples of compliant and non-compliant documentation.

Colorectal Screening. On this example you can see that the member’s information is clearly visible. Their name and date of birth. For this one, underneath the surgical history, we have that the colonoscopy was performed and the date, month and year. We do not need the results of the colonoscopy, but this one does have it. This would be a compliant chart for colorectal screening.

Or we can accept the actual report from the colonoscopy or the test performed.

As previously noted, some HEDIS measures need to be completed within a specific time or age frame. For the FOB Test it is compliant if it’s done during the measurement year, but as you can see underneath this lab, it indicates that this test was performed in 2019, which is outside of the HEDIS timeframe for this type of screening. So this member would be non-compliant.

Diabetic Eye Exams. For this measure we need to see that the member, who has a diagnosis of diabetes, was screened for retinopathy. If the screening was done in the measurement year, it would be compliant regardless of positive or negative results. But if the result was positive in the year prior that would be noncompliant. We can only accept negative results from the year prior. This is discussed in more detail in the Adult Measure WebEx. Again, please reach out to your Clinical Quality Improvement Liaison for additional information.

Again, a compliant diabetic retinal eye exam, as previously noted, we can accept negative results from the previous year. Also, it does not have to specifically say, “No diabetic retinopathy,” but must be clear that a retinal exam was performed.

Non-compliant Diabetic Eye Exam. In this example, we can see that there is no information pertaining to a retinal and/or dilation of the eyes during the exam. So this member would be non-compliant because the documentation does not support the information required.

There are a few different ways in which ways you can submit clinical documentation securely. The first way is through Horizon Docs, which is the recommended way. Horizon Docs is a web-based centralized document repository that allows Horizon to exchange documents securely with Network Providers and it is accessible via the NaviNet Provider Portal. In here the documents are organized by category and sub-category. Designated users will receive email notifications when Horizon sends a document and those documents are based on the TIN number. Users are assigned permission to view the documents based on sensitivity level. The providers assign users’ permissions based on the type of documents they would be able to view. Again, we have another webinar specifically on HorizonDocs. Please reach out to your Clinical Quality Improvement Liaison for information on all the available WebEx’s.

Horizon Docs can be accessed through the NaviNet under the Workflow after your office has set up your clearance.

Horizon’s Secure Blue email is a safe and secure tool for submitting and uploading clinical documentation. Secure Blue encrypts any documents that contain any type of PHI. To use Horizon Secure Blue, the provider has to register with an initial secure blue e-mail is sent. Over the next few slides, we’re going to show you different screens on registration.

You will receive an e-mail through Secure Blue, this is what you will see. You will need to click on the “View Message.”

The first time using Secure Blue will prompt you to create a password. Simply complete the required fields shown here.

Once the account is created, you will be able to log in and retrieve emails and send supplemental data. It is recommended that you save the link as a favorite to be able to access the site moving forward.

When you use the link, you will be prompted to enter an email & a password that you registered. If for any reason you get a message to reset your password, you will need to reach out to your CQIL. Your CQIL will need to submit a request to reset your password for you.

As previously noted, HorizonDocs platform is the best way to submit supplemental data. Other options are through secure blue e-mail and managed file transfer site or MFT for providers who actually have an MFT. For Medicaid, the files should be placed in the “Medicaid Supplemental Data” folder. Providers who have an MFT site. If you do not have an MFT site for Medicaid, you can send the supplemental data to Medicare Advantage Value-Based Programs, for the MA Value-Based Providers, they will use the MFT site, placing the files in the “Medicare Supplemental Files” folder. Medicare Non-Value-Based or FIDE-SNP Providers, for providers who do not have the MFT, they will then submit supplemental data to For any of these emails or information pertaining to the MFT sites, again, please reach out to your CQIL.

Let’s talk about some best practices. One of the main things with supplemental data is that you do not have to wait until the end of the year to submit supplemental data. You can submit it throughout the entire measurement year. Refer to your 2021 Provider Tips for Optimizing HEDIS Results booklet to obtain suggested codes. Incorporate templates and ticklers in your EMR system as a reminder of HEDIS recommended screenings. Develop EMR standing order sets capturing applicable coding requirements. Have a designated office staff tasked to gathering and submitting supplemental data. Be diligent with monthly submissions and submit supplemental data year-round.

In the next few slides, you will see available resources that are offered to you in the Results & Recognition Programs. Please reach out, again, to your CQIL for copies of these resources. An integral part to your success in the programs is correct coding. The number one way to close gaps in care is through correct coding at the time of service and/or treatment is rendered. This booklet can be used as a resource if you are not sure how to code for a service and/or treatment rendered, to close the gap in care. Again, I must advise you, we do not and cannot tell you how and what to code. You have to code according to the services and/or treatments rendered and documented in the medical record.

The Provider Practice Transformation Manual provides information regarding the Quality Program Measures, it offers Best Practices, explains the Provider role in HEDIS, and has information regarding the CAHPS and HOS surveys as well as information on Horizon Healthy Journey.

The Provider Administrative Manual is an administrative procedure guide and provides information on authorization policies, member benefits, claim submissions and a vast array of other informative information to assist the provider with a day-to-day operations. To obtaining a copy, again, please reach out to your CQIL. It is also located on the Horizon Provider Portal or you can call 1-800-682-9091 for a copy.

So the best way to be successful is through claims submitting with codes that capture the service and/or treatments administratively. This will decrease or even remove the need to submit supplemental data and also improves timeliness of closing gaps in care.

Thank you for listening. If you have, any questions please feel free to email them to:

Discuss importance of clinical documentation, compliant versus non-compliant clinical documentation, supplemental data, Horizon Docs and Secure Blue messaging.