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What’s the Code?

What’s the Code?


Hello and welcome to the 2021 Results & Recognition's Program’s presentation on What’s the Code. Just a brief disclaimer, that we are not certified coders and will not provide instruction on how to code or what codes to use for services rendered. This presentation is designed to provide general information regarding the importance of accurate coding to close gaps in care.

The objectives of this presentation is to: Understand how care gaps are closed, Analyze Administrative and Hybrid Data, Understand the importance of accurately coding claims, Identify resources available, as well as Promote usage of the HEDIS Billing Tips Booklet

An integral part to your success in the Results & Recognition Program, also known as the R&R Program, is correct coding, which happens to be the number one way to close gaps in care is through correct coding at the time of service and you do this with CPT, CPT II or ICD 10 codes. We have a document called the Provider Tips Booklet and it entails the HEDIS quality value set codes set forth by the National Committee for Quality Assurance, which is NCQA. Again, we are not certified coders, we do not tell you how and what to code, you code according to the services you render and the documentation in the medical record has to support that. However, we do provide a billing tips booklet as a resource because if you are not sure how to code for a service and treatment you’ve provided to get quality credit for, this booklet may assist you in doing so.

So HEDIS rates are captured by either administrative or hybrid data. Both methods are used to look for numerator compliance. Numerator is the term used to equate how many members are compliant for the measure. Administrative data is used to identify the eligible population; the eligible population is also known as the denominator. The reported rate is based on all members who meet that eligible population criteria and who’ve been found to have received that service for the numerator through administrative data. Hybrid data is the information collected from the medical records to meet the numerator criteria if it’s not received by administrative data. HEDIS data collection is a year-round process using claims data as the primary source. In simple terms: administrative data comes from claims and hybrid data from medical record review. Accurate and timely submission of that administrative data, again known as claims, reduces the necessity of medical record review.

The HEDIS Value Set is the complete set of codes used to identify the services or conditions included in the measure. HEDIS-acceptable codes are published each October in the Value Set Directory, which is part of the final specifications published by NCQA. NCQA is the organization that developed HEDIS which is a set of standardized performance measures designed to ensure that the public has the information it needs to compare organizations’ performance. The HEDIS value set codes include codes from CPT, CVX, HCPCS, ICD-10, & LOINC; these are bare bone definitions noted, it’s not an all-inclusive list of the value set codes, and it’s up to the practice, provider and the biller to know how to apply these to services rendered.

Horizon uses The Evaluation and Management Services Guide from CMS to determine the appropriateness of coding submitted by providers and other health care professions, including the use of modifiers. Modifiers are used to report that the procedure has been altered by a specific circumstance. When are added to CPT or HCPCS codes, and that provides additional information about a service or procedure. Modifiers should not be used for multiple evaluation and management events unless the activity occurs at separate times on the same day.

The Provider Administrative Manual has a section related to the use of modifiers and can provide some useful information for you. The link and phone number will be provided at the end for those of you would like to obtain a copy of this manual. HEDIS data collection is a year-round process using claims data as the primary source. Supplemental data submissions are secondary sources and these are discussed in greater detail in the Achieving Quality Compliance presentation. Complete and accurate coding of all claim submissions is a priority because it ensures the integrity of the data. Claims submissions should also be timely to avoid any delays in monthly updates for reporting of this data. When you close the care gaps, it reflects on your performance report and you receive an incentive once that measure exceeds NCQA’s 50th percentile benchmark or reaches the Star measure target.

The Provider HEDIS Tips Booklet is a resource we provide to the R&R Providers. It lists some key HEDIS measures in the R&R Program, corresponding suggested billing codes and documentation requirements. Please always keep in mind that any codes used must support the services rendered and be reflected in the medical record documentation. If you have not received the 2021 version, please reach out to your CQIL.

This is a snapshot of what the HEDIS Tips Booklet looks like. This page lists the Breast Cancer Screening and Care for Older Adults measure. It gives you the HEDIS measure, the data collection method, a description of the measure, the numerator compliance meaning what will make the measure compliant, and the quality value set codes listed by NCQA. We will not review every measure but speak to only a few of them. So let’s take a look at a chart example for COA, which is Care for Older Adults. Dr. Doe saw Roy Rogers on 2/2/21 for an office visit and the doctor did a medication review at that time. The doctor submitted a claim on that same DOS, so he did that in a timely fashion, and he included the ICD-10 code of 90863, which reflects the rendered service of a medication review. So needless to say, this chart met compliance via claims data and it has the supporting documentation in the medical record.

Ok, looking at another page in the HEDIS Billing Tips Booklet, this page displays information for the Comprehensive Medication Review and Controlling High Blood Pressure measures. So let’s look at a chart example for Controlling High Blood Pressure.

Mrs. Rosey had an office visit with Dr. Jones on 1/13/21. The doctor took her blood pressure, which was 110/62, and we know this is a compliant because it is under 140/90. Dr. Jones submitted a claim on that DOS but the doctor DID NOT include the CPT codes to reflect the systolic & diastolic readings. The doctor received his quality performance report and Mrs. Rosey still appeared as non-compliant even though there is supporting documentation in the medical record. If the doctor would like to correct this, close the gap for this measure and get the quality credit he deserves for performing the service, he can submit supplemental data to do so.

Let’s look at Weight Assessment and Counseling for Nutrition & Physical Activity, which is a pediatric measure that includes the 3 sub-measures of BMI percentile, nutrition & physical activity counseling.

Dr. Noodle saw Anna Bella on 2/1/21 and he completed a BMI percentile, as well as nutrition and physical activity counseling at that visit. He submitted the claim and included ICD-10 codes Z68.52, Z71.3, & Z71.82 – all three of these codes reflect the services of each sub-measure. The medical record has clear documentation of all the services rendered and has met compliance through claims data.

Ok, so let’s talk a little bit about telehealth. With the current state of affairs and all that is and has been going on with the COVID pandemic, telehealth has become a valuable commodity. Horizon shall identify telemedicine services when modifiers 95 or GT are appended to CPT or HCPCS codes that ordinarily describe face-to-face services including but not limited to, office or other outpatient visits, inpatient visits, or individual psychotherapy services. Reimbursement for telemedicine services may be available for real time communications that meet the requirement of a face-to-face consultation or contact between the provider and patient or telemedicine service limited to services involving the use of interactive, real-time, two-way audio-video communication technologies for the purpose of diagnosing, consulting or treating in accordance with the member’s contract. These are just a couple instances of when reimbursement could be applied to telemedicine services. Horizon’s website provides the policies & procedures related to the use of this service. Horizon’s website for providers gives you the policies & procedures. Many of the HEDIS measures within the R&R Programs now include telehealth services to help meet compliance and these measures have specific billing codes that NCQA has set forth to recognize these services. Those codes are noted in the Provider Billing Tips Booklet, which we’ve previously discussed. There is also a presentation specifically catered to Telehealth.

Not all services however, are eligible for Telehealth, such as: Non-direct patient services - Claims submitted with modifier GQ, which signifies services provided via asynchronous telecommunications system, an example of this could be emailing a member - Any service not eligible for separate reimbursement when rendered to the patient in-person is not eligible for telehealth services - The presentation facility fee, which is HCPS code Q3014, is also not eligible, and - The CPT codes 99441-99444; however, the exception to this is that during the public health emergency only the codes 99441-99443 will be considered for coverage.

Some important things to know about Telemedicine: Health care providers providing this service will be subject to the same practice standards as applicable to in-person settings. Documentation in the medical record must be maintained and support the services rendered. By coding and billing modifiers 95 or GT with a covered procedure code, the provider is certifying that the member was present at an originating site when the provider provided the telemedicine service; now originating site means a site at which a patient is located at the time the health care services are provided by means of telemedicine. Payment will be made at the same rate as that of the existing Professional Agreement Allowances; telemedicine services do not have different payment rates.

Ok, so switching gears a little, let’s talk about submitting a corrected claim with electronic data exchange, which is another option to close gaps in care, and the Provider Administrative Manual addresses this topic also in Section 9. Submitting a $0 corrected claim should be the very last option to be considered in closing care gaps and obtaining quality credit. When you do so, it can be done either electronically or by paper method. If you notice on your performance report that there are still open care gaps that you know have been addressed and is documented in the medical record, you can submit a corrected claim with the intention of closing those gaps. Maybe you didn’t use a code that was recognized. If you’ve already been reimbursed for those services you will not get paid again. BUT by submitting a $0 claim, you will receive the quality credit to count towards your site’s performance and earning the incentive.

A corrected claim is defined as a resubmission of a claim with a specific change that has been made, such as changes to CPT codes, diagnosis codes or billed amounts. It is not a request to review the processing of a claim. The electronic corrected claim submission capability allow for faster processing, increased claims accuracy and a streamlined submission process, and you can also refer to section 9 in the Provider Administrative Manual. If you do have any questions about the process, there is a dedicated team that can answer those questions, so please feel free to reach out to them.

If you choose to file a corrected claim by paper, which is known as the CMS-1500, this is what the form would look like, you will submit with the appropriate resubmission code and a copy of the original Explanation of Payment with the original claim number for which the corrected claim is being submitted. Also, you should not complete both an electronic & paper $0 claim for the same service because that will be a duplicate and will create a problem on the back-end of claims, so you will pick one or the other and submit only once. Also, please verify with your billing-clearing house, if you use one, that the max number of codes are being pushed through. So an example would be if you’re coding for 10 different codes, you want to make sure ALL of those codes are being pushed and NOT just the first 5. Again, if you have any questions about this process, please refer to section 9 in the Provider Administration Manual or call the toll-free number listed on the previous slide.

So best practices… Complete and accurate coding of all claim submissions is a priority and will ensure the integrity of the data, as mentioned earlier. You want to make sure that the medical record documentation reflects all services billed. Revising super bills, which are your paper coding forms, to capture applicable coding requirements does help. A superbill is usually used by providers, as I am sure many of you are already familiar with, and is the primary source of data for creating claims, claims that will eventually be submitted for reimbursement. Claim submissions should be timely to avoid delays in monthly updates to tracking reports. Lastly, referring to the Provider Tips Booklet can definitely assist in choosing the appropriate suggested codes according to the services you’ve rendered and that are documented in the medical record.

The Provider Practice Transformation Manual is another resource that is provided to you. It provides information regarding the Quality Program Measures and Best Practices, the Providers’ role in HEDIS, it gives information on the CAHPS and the HOS surveys, as well as Horizon Healthy Journey. Your CQIL can provide a copy of this to you.

The Provider Administrative Manual, which I’ve referenced a few times already, is not exclusive to the R&R Programs. It is a guide for administrative procedures of Horizon NJ Health and is updated periodically. It can assist with questions on referrals, benefits, appeals, claim submission, and a slew of other topics. The manual is available on-line, which is the best way to access so you have the most recent version. However, if you would prefer a hard copy, please feel free to call the toll-free number noted here to make that request. That concludes this presentation on What’s the Code. Thank-you for listening. If you have any questions, your CQIL is always your first line of support, however, you are also welcome to send us a question or a message via the email noted here, which is, Our CQIL can provide a copy of this slide deck to you as well. Thank-you again.

Explain how care gaps are closed, hybrid & administrative data, coding claims to reflect services rendered, and using the Provider Tips Booklet.