Care Coordination is a broad concept that includes a wide range of activities within a medical home.   In next month’s newsletter we will provide more details regarding practice roles in care coordination.   

Expanded Role for Practice (and the potential for higher reimbursement)
Your practice already includes most of these activities in your routine care in some form. Some of these activities will be provided by the RCCO.   It is our understanding that the RCCOs are in the process of determining which activities they will provide an extra incentives to practices for providing. We have been providing input into these decisions with some RCCOs.  And practice managers will have a chance to provide input at our next practice manager’s meeting on August 18, 2011

Some practices will opt to provide all of these care coordination services.  Other practices will decide to provide a smaller number of them. After discussing this with several primary care practices, it appears that most primary care practices (medical homes) will want help in learning how to incorporate certain care coordination activities into their practice to meet the requirements and earn incentive payments.  

CCHAP’s Role
CCHAP is working with the RCCOs, the Colorado Chapter of the American Academy of Pediatrics, the Colorado Academy of Family Practice, The Colorado Medical Society, The Department of Pediatrics at UC Denver, Children’s Hospital Colorado and Health Team Works to develop a program to coach practices interested in expanding their care coordination capabilities and to develop a set of tools that will help practices streamline care coordination activities and work flow so it can be cost effective and  improve patient outcomes.  CCHAP is also working with pediatric specialists statewide to develop systems and tools to improve communication between a child’s medical home and pediatric specialists.  CCHAP will provide information, coaching and helpful tools to assist practices in developing the level of care coordination they wish to provide.

This is the first in a series of articles that will appear in our newsletters over the next 2 years as Medicaid reform in Colorado (the Accountable Care Collaborative) evolves and as RCCOs implement their plans.

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Practice Manager’s Corner

REMINDER:  Practice Manager Meeting has been moved to Thursday August 18th at noon (rescheduled from July 20th).  We will discuss updates to Medicaid Reform and provide an opportunity for practices to give feedback to the Regional Care Collaborative Organizations (RCCOs).  More details to come...

DELAY IN IMPLEMENTATION OF NEW MEDICAID PROVIDER RATES
Provider rates will be reduced beginning July 1, 2011 to help balance the state budget. This reduction was announced in the June 2011 Provider Bulletin. Although the effective date is July 1, 2011, approval is pending from the Centers for Medicare and Medicaid Services (CMS), to implement the change for all reductions, except for Home and Community Based Services. The new rates for services delivered on or after July 1, 2011 will be retroactively applied once approval is granted. Until approval is received, providers will be paid at the 2010-11 rates. For Home and Community Based Services, the rate reductions will be applied beginning July 1, 2011. HCPF apologizes for any administrative difficulties this presents. They are working as quickly as possible with CMS to implement the new rates. Please contact Jeanine Draut at Jeanine.Draut@state.co.us or 303-866-5942 if you have any questions.

IMPORTANT: Please be assured that CCHAP, along with the Colorado Chapter of the American Academy of Pediatrics and the Colorado Academy of Family Physicians continue to advocate for fair reimbursement on behalf of providers in Colorado who take care of Medicaid patients.

Link to the July 1, 2011 Medicaid Fee Schedule

COLORADO ACCESS CHP+ FEE SCHEDULE UPDATES

• The CHP+ State Managed Care Network will adjust the provider reimbursements effective 7-1-2011 to follow the RBRVS Medicare fee schedule that was in effect January 1, 2011.  This rate will not change for the fiscal year of 7-1-2011 through 6-30-2012.
• The CHP+ HMO offered by Colorado Access plan will continue to use the most current Medicare RBRVS fee schedule.
• Both plans will continue to reimburse Developmental Delay and Depression Screening codes based on each plan’s RBRVS fee schedule rate.

DEVELOPMENTAL, DEPRESSION AND AUTISM SCREENS
Effective for dates of service on or after August 1, 2011, Medicaid has issued the following policy for developmental and depression screens, and set the following rates for CPT codes 96110 and 99420. The Colorado Medical Assistance Program will reimburse developmental screening code 96110, at $17.00 and depression screening code, 99420, at $10.08 effective 8/1/2011. Developmental Screening for dates of service prior to August will be reimbursed per the applicable fee schedule.

Developmental Screening
The Colorado Medical Assistance Program covers developmental screening for children ages 0 – 4, using a standardized, validated developmental screening tool (e.g., PEDS, Ages and Stages) at the child’s periodic visits. In the absence of established risk factors or parental or provider concerns, the American Academy of Pediatrics (AAP) recommends developmental screens at the 9th, 18th, and 30th month, and 3 and 4 year well-child visit.

Limitations:
Three (3) screens per year for children aged 0 – 24 months
Two (2) screens per year for children aged 25 – 59 months

Providers should report CPT code 96110, “Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report,” when providing developmental screens.

To report a positive screen:
Use a valid diagnosis code within category 315, “Specific Delays in Development,” category 313, “Disturbance of Emotions Specific to Childhood and Adolescence,” category 314, “Hyperkinetic Syndrome of Childhood,” for specific delays in mental development.

Use a valid diagnosis code within category 783 (using 4th and 5th digits when needed), “Symptoms Concerning Nutrition, Metabolism, and Development,” for physiological delays.

To report a negative screen:
Use code V20.2, “Routine Infant or Child Health Check.”

Providers should report CPT code 96111, “Developmental testing; extended (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instrument) with interpretation and report,” when a limited developmental screening suggests an abnormality in a particular area of development and more extensive formal testing is needed to evaluate the concern.

Depression Screening
The Colorado Medical Assistance Program covers depression screening for adolescents aged 11 – 20, using a standardized, validated depression screening tool (i.e., PHQ-9, Columbia Depression Scale, Beck Depression Inventory, Kutcher Adolescent Depression Scale, etc.) at the child’s periodic visits.

Limitations:
One (1) screen per year for adolescents aged 11 – 20 years

Post-Partum Depression Screening: providers may choose to screen adolescent clients for post-partum depression as part of the client’s annual depression screen. However, post-partum depression screening is a non-covered benefit for Medicaid clients aged 21 and over.

Providers should report CPT code 99420, “Administration and interpretation of health risk assessment instrument (e.g., health hazard appraisal),” when providing depression screens.
 
To report a positive screen, use diagnosis code V40.9
To report a negative screen, use diagnosis code V79.8

Autism Screening
Colorado Medicaid covers autism screening for children aged 18- and 24-months, using a standardized, validated depression screening tool (i.e., M-CHAT) at the child’s periodic visits.

Limitations:
Two (2) screens per year for children aged 18 – 24 months

Providers should report CPT code 96110, “Developmental testing; limited (i.e., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report,” when providing autism screens.

To report a positive screen: Use a valid diagnosis code within category 299 (using 4th and 5th digits when needed), “Pervasive Developmental Disorders.”

To report a negative screen: Use code V20.2, “Routine Infant or Child Health Check.”

Screening Tools
The Colorado Medical Assistance Program does not require the use of a specific developmental screening tool, but providers must use a validated, standardized developmental screening tool.

The Colorado Medical Assistance Program recommends the use of PHQ-9 depression screening tool, but other validated, standardized depression screening tools are also acceptable.

Referrals to Care
If a behavioral health need is identified, the primary care clinician must offer to either: Provide the necessary services; or Refer the patient to a specialist.
Primary care providers who choose to refer a client to a specialist must assist with the referral process.
For more information on which Behavioral Health Organization (BHO) to refer pediatric clients, visit the BHO section of the HCPF Web site at www.colorado.gov/hcpf.

Please contact Sheeba Ibidunni at Sheeba.Ibidunni@state.co.us or 303-866-3510 with any questions.

CAVITY FREE AT THREE BILLING AND REIMBURSEMENT CHANGES
Effective for dates of service on or after July 1, 2011, Medicaid will no longer reimburse claims for oral hygiene instruction (D1330). However, providers will be able to bill for dental screening instead, using code D0999. This change applies to children ages 3 and 4. Reimbursement rates will be per the upcoming July 1, 2011 Medicaid fee schedule. Also, effective for dates of service on or after July 1, 2011, fluoride application (D1206) is limited to a maximum of three applications per patient per state fiscal year (July 1 – June 30).
Please see Medicaid Provider Bulletin July 2011


CHP+
The following services are covered by the CHP+ State Managed Care Network when provided by your assigned in-network PCP:  
     •    Fluoride varnish services provided in your PCP’s office.  
     •    Up to 2 fluoride varnish treatments in a calendar year for children ages 0 - 4.
     •    A risk assessment prior to varnish.
Fluoride varnish may also be provided by an in-network dentist.  When provided by a dentist these services are covered by Delta Dental under the routine dental benefit.  
Regarding reimbursement
CHP+ will follow Medicaid and eliminate D1330 (oral Instructions) as a reimbursable service effective on and after July 1, 2011. Like Medicaid, CHP+ will open up a new code D0999 for Unspecified Diagnostic Procedures. There will be an announcement in the CHP+ Provider Bulletin around this change. This effects very few CHP+ members e.g., those living in Teller, El Paso and Sedgwick County (counties not served by a CHP+ HMO) who use their PCP for their FV benefit instead of the usual Delta Dental CHP+ providers.

PEDIATRIC IMMUNIZATION CODES 90460 AND 90461 BILLING CLARIFICATION
In the January 2011 Immunization Bulletin, the Department published instructions on how to bill the new pediatric immunization codes 90460 and 90461. Since that bulletin, the Department has received numerous inquiries on how to properly bill these new codes and is now issuing the following clarification: Please see Medicaid Provider Bulletin July 2011

CIRCUMCISION BENEFIT
Due to legislative change, circumcision will no longer be a covered benefit under Colorado Medicaid effective for dates of service on or after July 1, 2011.  The following CPT codes will no longer be reimbursed: 54150, 54160, and 54161.

Important Note: Page 19 of the COLORADO MEDICAL ASSISTANCE PROGRAM GENERAL PROVIDER INFORMATION Manual states: “If the service is not a covered benefit of the Colorado Medical Assistance Program, clients may be billed for the service. Before providing services that will not be covered by the Colorado Medical Assistance Program, providers should have the client sign an acknowledgment of financial responsibility.”
Email Kevin.heckman@childrenscolorado.org to request a form that may be used for this purpose.

This change to Medicaid does not impact the Child Health Plan Plus (CHP+) program.  
CHP+ will continue to include the newborn circumcision procedure as a covered benefit. One of the tenets of the enabling legislation for the Children’s Health Insurance Plans (CHIP, known as CHP+ in Colorado) was for states to design a benefit plan similar to commercial insurance, sometimes referred to as a “benchmark” benefit plan. All of the CHP+ managed care organizations that offer a commercial health insurance product include the newborn circumcision procedure in their benefit package. To be consistent with the enabling legislation, CHP+ will continue to include this procedure as a covered benefit.

If you have further questions regarding the CHP+ circumcision policy, please contact:

Alan S. Kislowitz, MSHA
Health Plan Manager
Colorado Dept. of Health Care Policy and Financing
Child Health Plan Plus Division
(303) 866-3646
Alan.kislowitz@state.co.us

ELIGIBILITY VERIFICATION
The Department of Health Care Policy and Financing (the Department) would like to remind providers to always verify eligibility before rendering services. After obtaining the birth date and State ID or SSN, the provider can conduct an eligibility request to determine the client’s eligibility status. The provider who checks a client’s eligibility on the day of service and finds the client eligible receives an eligibility guarantee number. If eligibility has changed when the claim is submitted, the guarantee number exempts those claims from eligibility edits for that date of service. Following this process today can help avoid problems later.
Providers can verify eligibility through one the following:

Colorado Medical Assistance Program Web Portal (Web Portal) - Batch or Interactive:
X12N 270 – Eligibility Inquiry
FaxBack: 1-800-493-0920 Toll-free
Provides fax responses to client eligibility requests
Colorado Medicaid Eligibility Response System (CMERS)/Automatic Voice Response System (AVRS): 1-800-237-0044 Toll free
CMERS is an automated voice response system that furnishes providers with information ranging from client eligibility to provider warrant and claim status information.

ICD-10 TRANSITION
The ICD-10 transition affects everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), even those who do not submit Medicaid claims. Anyone covered by HIPAA must use ICD-10 diagnosis codes for services provided on or after October 1, 2013. To be prepared for this transition, you should begin planning now if you haven't done so already.
Here are a few of the many areas where the transition to ICD-10 will affect your practice:

• More robust codes. Codes will grow from 17,000 to 140,000. Code books and styles will completely change.
• Updated policies and procedures. Any office policy or procedure tied to a diagnosis code, disease management, tracking, or Prior Authorization Request (PAR) must be changed. 
• Medical record documentation. ICD-10 codes will better reflect the specificity already inherent in the patient's medical record. Physicians will need to continue to document the patient's plan of care to include laterality, stages of healing, weeks in pregnancy, episodes of care, etc. Other health care professionals will also need to continue to document patient information with specificity. The Health Care Policy and Financing Department is strongly recommending all providers review their documentation. 
• Providers should determine where ICD-9 codes currently appear in your systems and business processes. Consider budgeting for training, re-printing of superbills, evaluating all vendor and payer contacts and developing an ICD-10 timeline.

Keep Up to Date on ICD-10. The Centers for Medicare and Medicaid have a web site that includes factsheets, timelines, and additional resources to assist you with the transition to ICD-10 codes. Please visit the CMS website for the latest news and resources to help you prepare!

RX REVIEW PROGRAM
The Rx Review Program is a voluntary participatory medication review for Medicaid clients who are high drug-utilizers (five or more drugs each month for three consecutive months). Statewide consultations will be conducted by contracted pharmacists beginning in late August or early September 2011 with providers and patients receiving a recommendation letter from the pharmacist. Evaluations include educating the patient and a review of all prescription medications as well as over-the-counter drugs and nutritional supplements, identifying drug-drug interactions, drug duplication or use of multiple providers as well as conformity with the Preferred Drug List (PDL). Your initial promotion of the program will help ease your patients’ apprehension to participate once Medicaid and the pharmacist contact them. Since patient participation is voluntary, their pharmacy benefits will not be affected in any way.
Please contact Tammie Ruiz at Tammie.Ruiz@state.co.us for more information.

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How Culture Can Contribute to No-Show Rates

Written by Marcia Carteret M.Ed.

I have relied on the expertise of Kevin Heckman, CCHAP Program Administrator, Erlinda DeLuna, CCHAP Manager of Care Coordination, and Lorena Counts, CCHAP Resource Coordinator for this article. Kevin, Erlinda and Lorena all have extensive first-hand experience working with patients from different cultural backgrounds in private practice and clinic settings. Kevin also lends to this discussion his own experiences as a private practice manager

American medical culture is "clock-time" driven, and while time is money for nearly every business in our society, a private practice or clinic lives by its schedule of appointments.  Statistically, private practices and clinics experience more no-shows among lower income (Medicaid and CHP+) patients. While there is no doubt that cultural differences often contribute to the problem, socio-economic realities for families are a crucial co-factor. The way practices and clinics communicate with their patients may not eliminate no-shows, but can make a difference in reducing the rate of missed appointments. Better communication begins, as always, with understanding the values and beliefs that drive people's behavior. In this article we look at the relevant cultural values and beliefs as well as the kinds of life circumstances that often underlie a pattern of missed appointments.

Contributing Factors and Dimensions of Culture

Contributing Factor 1: Preventive Medicine is an Unfamiliar Concept
In many societies around the world, there are immediate treatments for illness and injury, but little concept of preventive medicine in the way the American medical establishment conceives of it. In many cultures, if you are sick you go to the doctor, but if you aren't sick there is no reason why you would seek out a doctor or traditional healer just to BE SURE you aren't sick or to keep you from getting sick. In one example from a case Erlinda recently handled, a mother from Mexico kept missing her well-child check-ups. The mother would make follow-up appointments before leaving the doctor's office, but she would never show up for them and never call. Erlinda was assigned to her case and, upon contacting the woman, understood the problem immediately. The woman did not see any reason for going to the doctor because the doctor had told her that her son was "well". Why, she asked, would she take her child to the doctor when she knew the child was healthy? She also said that her child screamed and cried after getting shots at the doctor's office and she felt uncomfortable about putting him through more of the same if he wasn't sick. Once Erlinda explained the concept of well-child checks, the mother understood the importance of keeping these appointments. Erlinda says, "There's a much better chance of the mother making her appointments now that this misunderstanding is cleared up. When people know the reason for things, and if it makes sense to them, they are more likely to make it a priority to comply."

Contributing Factor 2: Who Controls Our Well-Being?
It is also important to remember the dimension of culture "control over destiny." For people who have a strong belief in fate and karma, what happens to them in life - good or bad luck, health or illness - is in the hands of their higher power. Therefore, self-management of one's health for a better future outcome won't drive behavior in significant ways. (Even Americans, who by comparison, believe that control over destiny lies with themselves, are slow to make appointments for routine physical exams. And how many of us keep putting off that visit to the dentist for teeth cleaning?) It is useful to keep in mind that culture and religion are two sides of the same coin; many beliefs associated with fate and karma are based on guiding religious principles and, for that reason especially, cannot be negated or dismissed by outsiders. It is important to show respect for people's beliefs, but also to explain that the "higher power" has also made western medicine available.
 
Contributing Factor 3: Status of Health Care Professionals
Consider another cultural component in the case of the mother who kept missing her well-child checks prior to Erlinda counseling her. This mom nodded in agreement when her doctor told her to schedule the next check-up. She did not ask the doctor why she should bring her healthy child back to see him in two months' time unless he was sick. She didn't want to waste any more of his time. She followed his instructions and made the next appointment at the front desk. She did not write down the appointment. When the receptionist handed her a card with the appointment time written on it, she tucked it in her pocket. She was nodding and smiling pleasantly but not really looking forward to the next visit in a committed way. She was going through the motions to please the practice; she felt she needed to do this in order to be able to remain a patient of the doctor she liked.

She had forgotten about the appointment until a reminder call came from the doctor’s office. On the day of the appointment, however, her child was healthy and happy. She thought it would be a waste of the doctor's time to take the boy in. She also thought that if she didn't show up, it just made the line of patients waiting for the doctor shorter. Where she came from, it was always first come-first served at clinics.

Contributing Factor 4: Time Control/Management
As stated at the very beginning of this article, Americans have a very specific attitude about time. We manage time down to the minute. Our healthcare appointments are based on absolute time, whereas in many societies healthcare is much more informal. Appointments work like general admission to a concert. People who are more relaxed about managing time often do not keep calendars - on paper or electronic devices. They certainly don't track their personal/family time which is typically the most important aspect of their lives. Lorraine explains, "So often the parent isn't prepared to write down the next appointment in a calendar when she is standing in the doctor's office. When a practice calls the day before an appointment as a reminder, the person may have forgotten all about it and simply can't arrange transportation with only a day's notice."

Why wouldn't a person in this situation explain their situation and ask to re-schedule? A parent’s explanation might sounds something like this:  "Well I hoped somehow I would find someone to take me. I was still trying to get my cousin to help me even when I was already late to the appointment. But when I knew I couldn't go, I was afraid to call the doctor. They would be angry with me."

An added note: We all know people who just don't check their messages frequently, don't return calls, don't read their email and respond. Individuals vary greatly with respect to these behaviors - no matter what culture they come from. There may be important messages from a doctor's office lost in a long backlog of voice-mail messages on someone's phone. Their phone service may even be cut off. When patients/families have low English proficiency, low literacy and low health literacy, relying on voice mail messages can be very problematic.

Contributing Factor 5:  Money Problems
Recently, I overheard an exchange between the front office staff at a practice in Denver where a father had shown up with his son for an appointment only to discover there was an outstanding balance of $800 that needed to be paid before the doctor would see his child. I worried. In these economic times, what if the dad is out of work? How humiliating it would be if he couldn't pay. But this is the way our system works in the U.S. In many other places in the world, "condition" determines care, not money or proof of insurance. In some cultures, the doctor establishes a more personal relationship with patients/families over time. Everything is much more informal. A physician or community healer may allow patients to pay in increments and will still continue care. And of course the economic reality in our own system is that people who have credit cards can pay incrementally over very long periods of time. Those who struggle to establish credit and those who have exceeded their credit limits do not have this option.

IMPORTANT NOTE: Even with Medicaid, families can have outstanding balances that will prevent them from showing up for an appointment. Medicaid is retroactive only three months. Any bills pre-dating the three month period are the responsibility of the patient. CHP+ does not have any retroactive period at all. The shame of owing money to an authority figure like a doctor would be significant for many people.

Contributing Factor:  Transportation Problems

Finally, transportation challenges are an enormous contributing factor to no-shows. Imagine not owning a car or sharing a car among numerous family members. Imagine if you are a woman and your culture dictates that women can't drive themselves. Perhaps you can't get a male family member to take you. What if you can't afford gas? If you have no choice but public transportation, it probably won't be as convenient as a taxi. Imagine walking to a bus stop pushing a stroller in summer heat or winter snow. Imagine waiting for a bus that is late or never comes. Imagine having to navigate the bus with one child in a stroller and one or more toddlers in tow? It isn't likely patients will call the doctor's office to explain their problems. They may want to avoid a conversation with a busy front office receptionist.  Or, perhaps their situation produces shameful feelings in them. Too often, people will avoid a situation entirely by not calling, not showing up, not rescheduling.

Summary

While there is no doubt that cultural differences may often contribute to the problem of missed medical appointments, socio-economic realities for families are a crucial co-factor. The way practices and clinics communicate with their patients may not eliminate no-shows, but can make a difference in reducing the rate of missed appointments. We offer a Well-Child Check handout in English and Spanish designed to help parents understand the importance of scheduling and meeting important preventive care appointments.

Well-child checks are key to the prevention of many health problems, but parents from different cultural backgrounds may not understand the concept of “preventive medicine” at all. They may assume that if their child appears healthy, there is no reason to visit a doctor. They will miss an opportunity to gain important information about their child’s nutrition, sleep, safety, infectious diseases that are going around, etc. Culturally- based beliefs and behaviors about a person’s control over their own destiny, the status of doctors versus patients, and individual time control may also contribute to missed appointments. In helping families understand the concept of “preventive care” practices and clinics can help raise health literacy and ultimately reduce health disparities.

(Copyright © 2010. All rights reserved.)

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Quality Initiatives and YOUR Documentation

Your practice already knows how important it is to have good documentation as part of the clinical record; but what about documenting your QI initiatives and the effectiveness of your intervention(s)?  

Part of PDSA, the STUDY phase, is completing your analysis. During this phase, you should ask your team to document answers to the following:

• Did my prediction hold?
• What was learned?  
• List problems, successes & surprises.
• What assumptions need revision?

A FEW TIPS:

• Hold QI Meetings – Not meeting regularly? Now is a good time to start! Regular meetings can help keep everyone focused and accountable, as well as become the driver of all of your QI efforts.
  • Record Attendance – who, what, when and where.
  • Keep Meeting Notes – If you discover a barrier to your original plan, be sure to document your findings, as well as your plan of action, how you will monitor progress, and your results.
• Keep Statistics – Keep  your data reports in a file (soft or hard), along with baseline data. Over time, you may notice sudden fluctuations in the numbers. You should spend some time investigating those fluctuations, and document your plan for addressing those changes, as well as your predicted results from your new plan. It may also be beneficial to summarize some data in run charts. (Run charts are graphs of data over time. For more information check with your QI Coach, or see: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Run+Chart.htm.)
• Perform Audits – Your original QI plan included monthly or quarterly reports and review. If you have been able to follow that timeline, congratulations! However, if you haven’t been doing the monthly/quarterly review, take a few moments to determine why and then plan to get back on track. Periodic audits, in addition to monthly/quarterly reporting, may also be beneficial. For instance, in addition to your data, you may find it useful to gather additional information, such as staff satisfaction, process compliance, etc.  At your staff meetings, review the data and findings. Doing so regularly will help you determine whether or not your corrective actions have performed as expected.

For more information about documentation, as well as downloadable worksheets and forms, check out
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/
You may need to register, but it’s free and worth it!

A QI Coach is available – for FREE – to CCHAP affiliated practices
wishing to improve their medical home. Call or email today!

Angie Goodger, MPH, MHA
Quality Improvement Coach
720-346-4903 Cell
720-285-1919 Fax
angela@cchap.org

Do you have specific process improvement questions or topics that you would
like addressed in future newsletters? Let us know! Contact your QI Coach today!

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Copyright 2011 Colorado Children's Healthcare Access Program and other entities as noted.

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