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Quality Care Gap Closure

The presentation Quality Care Gap Closure will explain how care gaps are closed, hybrid & administrative data, coding claims to reflect services rendered, and using the Provider Tips Booklet.

Quality Care Gap Closure


Hello, and welcome to the Results and Recognition Program's presentation on Quality Care Gap Closure.

Result and recognition is also referred to as R&R.

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 and clinical documentation to close gaps in care.

The objectives are to understand the importance of correct coding.

Understand the importance of clinical documentation and ways to submit that and also apply suggested best practices.

Submissions of claims and encounters with coding that administratively captures all required data through claims decreasing the need for medical record review and improving timeliness of closing gaps in care.

This is the goal for quality gap closure.

Coding correctly, HEDIS data collection is a year-round process using claims data as the primary source to close gaps in care.

Supplemental data submissions are secondary sources.

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.

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 National Committee of Quality Assurance and 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 different organization performance.

The HEDIS value set codes include codes from CPT, HCPCS, ICD-10, LOINC & SNOMED.

These are bare bones definitions that are noted it is not an all-inclusive list of the value set codes.

It's up to the practice, the 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 modifiers are added to CPT or HCPCS codes, 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. The link to obtain that manual is noted at the bottom of this slide.

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 have 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 is not received by administrative data.

Again, HEDIS data collection is a year round process, and it uses 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.

Clinical Documentation. Documentation plays an important role in data collection and reporting for HEDIS as well as validating the services for any codes captured through claims.

Documentation provides a valuable account of a patient's concerns as described to the provider and the provider's assessment and findings about the patient's condition, and the resulting treatment plans.

Clinical documentation provides uniformity and continuity of care across visits, hospitals and providers and it serves as a communication tool for all the healthcare professionals involved in the members care.

There are many malpractice lawsuits occurring nationwide, and when these medical records are being assessed they're looking at that documentation because medical records are considered legal documents.

Clinical documentation may also be useful for research and education.

Documentation is everything, you know, how the saying goes if it's not documented, it's considered not done.

Clinical documentation ties into correct coding. They work hand in hand.

If for any reason, there is an audit conducted documentation in the medical record, must support the charges submitted on the claim.

A procedure must be indicated and substantiated in the medical record to be accepted as a claim for that service.

There were 3 important reasons why documentation is important for claims.

First, it facilitates accurate and timely claims review and payment.

Second, it minimizes many of the challenges related to claims processing and HEDIS chart requests.

Third, it supports the HEDIS codes reported on billing statements.

When we're looking at medical records to close gaps in care, such as for supplemental data.

We need to see that the documentation supports the measure at hand.

Correct coding is the most accurate way to capture clinical quality data.

However, when the gap is not closed administratively, hybrid data may be submitted.

Clinical documentation should include the patient's name, date of birth, date of service, the provider signature and credentials, and a description of services rendered, either during an office or telehealth visit.

Some common reasons for non-compliant documentation.

Missing or incomplete required documentation components.

Incomplete services rendered another reason for non-compliance would be if a service was provided outside the required timeframe.

If the provider signature date of service, or the unique member identification is missing such as the date of birth, that would also be noncompliant. Some advantages of electronic medical records.

EMR templates, help providers, integrate all the necessary components for proper clinical documentation in a very clear and structured manner, as well, as assisting them in addressing specific areas for documentation purposes.

These templates simplify analyzing data and again, if these charts are audited all the information is right there and clearly documented.

A properly designed and implemented EMR system can actually prefill portions of templates needed to avoid errors in the patient's medical record.

It can also collect essential, HEDIS data and track, non-compliance and preventive services.

Another advantage with utilizing an EMR is that medical records can be more easily read and are less prone to have errors go unnoticed.

Submitting Clinical Documentation. If you are submitting medical records for supplemental data, or any other documents, there are a few different ways in which you may submit them securely.

The first way is through HorizonDocs, which is the preferred method.

HorizonDocs 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 portals.

Secure blue email and managed file transfer known as the MFT, are also options to send and receive documents securely.

However, these two methods will eventually be phased out at some point.

So, if you haven't yet started using Horizon Docs, I highly suggest you do so.

There will be an email at the conclusion of this presentation that you can contact for assistance in doing so.

There are many tools and resources that we offer providers in the R&R program. Let's talk about a few.

The first one is the provider HEDIS Tips Booklet.

Now, historically, we've distributed copies to the providers, but this resource is now only available electronically via the Quality Resource Center, which I'll touch on shortly. The HEDIS tips booklet lists things such as some key HEDIS measure descriptions, data collection methods, suggested codes and best practices.

Always keep in mind that the most accurate way to close quality gaps of care is to submit data through correct coding and any codes used must support the services rendered and be reflected in the medical record documentation.

When you access the Quality Resource Center, you will also be able to retrieve guidelines, manuals and measure specific information.

The Quality Resource Center can be accessed by visiting, and then signing into Navinet. It will be worth your while to access this site and explore all the tools and resources available at your fingertips.

The Provider Administrative Manual, as I previously discussed 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 online and the link to obtain this is noted here.

Some suggested best practices, submit accurate claim, and encounter data for each and every service rendered and ensure that the medical record documentation reflects all services billed.

Submit the claim and encounter data on a timely basis.

Incorporate templates and ticklers into your EMR system if you're able to, as a reminder of HEDIS recommended screenings.

Maintain and complete, excuse me, maintain a complete and accurate record of all rendered services, including telemedicine services.

Also, you can submit supplemental data year round you do not have to wait until the end of the year to do.

Lastly, utilize the Quality Resource Center.

You can access the provider HEDIS Billing Tips Booklet, best practices, program manuals and many other tools and resources.

So, that concludes this presentation on quality care gap closure. Thank you for listening.

If you have any questions, or you would like to know the process for setting yourself up for HorizonDocs, please send your inquiries to the email noted here.

Also in the transcript and below the webinar is a link to our survey monkey. Please complete this brief survey.

Your feedback is greatly appreciated. Thank you.

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