Ingenix InSite User Group

1. Ingenix InSite User Group May 11, 2010 Approval Code: IN154

2. 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.

3. 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

4. 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

5. Build-up RAF and RAF Calculator Presented by: Ian Moxley Analytics

6. RAF Types - CMS • 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

7. RAF Types – Build-up • 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.

8. Example of InSite Report with Build-up RAF • HCC RAF Detail Report Example

9. InSite Report(s) with Build-up RAF • All InSite Reports impacted by Build-up RAF • HCC RAF Detail • PCP RAF • Largest Declining RAF Quickview • Patient Management

10. Learning and Resources Deep Dive Review – Part 3 - Overview • Learning and Resources Tab • Utilities and Tools • RAF Calculator

11. RAF Calculator • 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

12. RAF Calculator • Step 1: Enter Member Information • 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

13. RAF Calculator • Step 2: Enter Special Status & Location • Key Points • Special Status: • Disabled: Y or N • Original Eligibility: Aged or Disabled • Community or Institutional • County Rate determined based on payment year

14. 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)

15. RAF Calculator • Step 3: Enter Diagnosis Information (HCCs) Error Handling: HCC Hierarchy • 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

16. 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

17. RAF Calculator • Results: Calculator Sheet 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

18. RAF Calculator • Results: Output • 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

19. TIA, Stroke & Late Effects of Stroke Presented by Mary Jo Groome, CPC-H, CCS-P Sr. Provider Training & Development Consultant Ingenix, Clinical Assessment Solutions

20. 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.

21. 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?

22. ICD-9-CM Official Guidelines for Coding and Reporting • The tense mattersto documentation and coding: • Diagnosis codes have been submitted for acute conditions when the beneficiary was status post • Or, had ahistory of the condition • Be cautiouswith the use of the following terms: • Acute • Status post • History of • Impending

23. Transient Ischemic Attack (TIA)

24. 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)

25. 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)

26. Stroke & Late Effects of Stroke

27. 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 thepresent tensewhen the coder is actually trying to code for the residual conditions left behind by aprior stroke.

28. Documentation of Stroke When Did The Event Occur? • DocumentAcute Strokeon first admission to the hospital only.(434.91) • DocumentResidual Deficits of Strokeon office visits following the acute incident. (438.XX) (Late Effects) • DocumentHistory of CVAif there are no residual deficits from a prior stroke code.(V12.54)

29. 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)

30. 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.

31. 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, Moderate Code: 138- “Late Effects” – poliomyelitis Normally, this is a two code scenario Stroke is the exception.

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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 disease Use 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.

38. 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)

39. 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

40. 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

41. A Final Word about 436 • 436 – Acute, but ill-defined, cerebrovascular disease Apoplexy, apoplectic: NOS attack cerebral seizure Cerebral seizure TIP: Do not assign when documentation indicates “CVA, stroke, or cerebral infarction.” See instead default code 434.91.

42. Ingenix / Team members would like to … Thank You Questions will be taken later

43. InSite Custom List for Printing Multiple Patient Assessment Forms (PAFs) Demonstration Presented by: Francesca Siciliano InSite Product Business Analyst

44. Overview of Downloading Multiple PAFs • Multiple PAF Download (By Criteria) • New functionality in InSite as of 3/31/2010 • Suggested Uses • 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 • 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 Highlights • Users have the ability to select member records from any report • User can add selected records to the custom list • User can add all records on the report to the custom list • 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 • User can delete the entire list or individual records if they decide to NOT export

45. March 2010 InSite Release • Multiple PAF Download (By Criteria) • User will have the ability to select member records from any report

46. March 2010 InSite Release • Multiple PAF Download (By Criteria) • 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

47. March 2010 InSite Release • Multiple PAF Download (By Criteria) • 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

48. March 2010 InSite Release • Multiple PAF Download (By Criteria) • 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

49. March 2010 InSite Release • Multiple PAF Download (By Criteria) • User can delete entire list or individual records the decide to NOT export To Remove the Entire List To remove an individual record from this list

50. User Group Feedback Discussion • Best Practices Agenda Item