powerpoint presentationpartnershiphp.org/providers/quality/documents/hedis/2019... · 2019. 1....

HEDIS Refresher-

Eye Exam Medical Record Documentation

Webinar

Presented by:

Martha Layne, RN, MHA

HEDIS Clinical Lead, PHC

Eureka | Fairfield | Redding | Santa Rosa

Webinar Instructions


Webinar Instructions

• All participants have been

muted to eliminate any

possible noise

interference/distraction.

• If you have a question or

would like to share your

comments during the

webinar, please type your

question in the “question”

box or click on the “raised

hand” icon.


Objectives

• Overview of HEDIS & Partnership Healthplan

• CDC- Eye Exam indicatorPathology of Diabetic Retinopathy

Importance of eye exams for members dx w/Diabetes

Importance of eye exam results being communicated w/PCP

Documentation to provide from the eye exam for HEDIS

• Contacts & Resources

• Q&A


Intro to PHC

Southeast: Solano, Yolo, Napa

Southwest: Sonoma, Marin, Mendocino, Lake

Northeast: Lassen, Modoc, Siskiyou, Trinity, Shasta

Northwest: Humboldt, Del Norte


Overview

• What is HEDIS?

• Healthcare Effectiveness Data and Information Set

• Why is HEDIS Important?

• Evaluates clinical quality in a standardized way

• Identifies opportunities for improvement

• Regional-level performance is publicly reported

• Regional-level reporting is required by the State

• HEDIS/CAHPS equates to 50% of NCQA Accreditation Score


Overview

Measure Reporting Methodology:

• Administrative Measures• Measures the entire eligible population

• Data collected through transaction data or other administrative data used to identify the eligible population and numerator (i.e. Claims/encounter)

• Hybrid Measures• Measures a statistically significant sample of the eligible

population

• Data collected from transaction data or other administrative data and key data elements collected from the medical record


CDC Measure

• Measure Description: the percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:

• Hemoglobin / HbA1c Testing

• HbA1c Poor Control (>9.0%)

• HbA1c Control (<8.0%)

• Eye Exam

• Medical Attention for Nephropathy

• Blood Pressure Control (<140/90 mm Hg)


Guest Speaker

• Dr. Sean Sumsion, OphthalmologistoBoard-Eligible Ophthalmologist

oCataract surgery, LASIK, and PRK

oContributor / author on 5 peer review articles

HEDIS Eyecare WebinarSean Sumsion, MD

Riverside EyeCare Professionals

January 23rd, 2019

Diabetes Burden

• US Data• Pre-Diabetes: 84.1 Million (33.9%)

• Diabetes: 30.3 Million (9.4%)• Diagnosed: 23.1 Million

• Undiagnosed: 7.2 Million (23.8%)

• Among age 65+: 25.2%

• Type 2: 95%

• Highest Incidence - American Indians, Alaska Natives, Non-Hispanic Blacks, and Hispanic ethnicity

• Lower Socioeconomic status Higher risk

National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2017.

More Statistics

• ADA• 1.5 Million New Dx each year

• 7th Leading cause of death in US

• Multiplier of 2.3 – cost of having diabetes

• Billions• $327 Total Costs

• $237 Direct Medical Costs

• $90 Billion Reduced Productivity

• Leading Cause of Blindness (18-64)

• 50% of pts have Peripheral Neuropathy

• Leading Cause of Kidney Disease (25% )

Pathology

• Microvascular disease – Nephropathy, Neuropathy, and Retinopathy

Mild Non-Proliferative DR

Moderate Non-Proliferative DR

Severe Non-Proliferative DR

Proliferative DR

Diabetic Eye Exam

• Recommendations:• Type 1: Annual screenings beginning 5 years after onset of disease

• Type 2: At time of diagnosis + yearly thereafter

• Gestational: Not require eye exam during pregnancy

• Only 60% of DM pts get yearly screenings

• Optometry + Ophthalmology• Prompt referral for NPDR, PDR, DME

• PRP, Anti-VEGF tx

• Eye = Kidney = Nerve

Real World Practice

• On date of Exam:• PCP

• Record Fasting glucose, HbA1c

• Exam findings including degree of Retinopathy (if any) and plan for tx/ follow-up

• Type +/- retinopathy; BDR vs PDR, DME

• W/o = 1 year

• Mild NPDR = 9 months

• Moderate NPDR = 6 months

• Severe NPDR = Tx + 3 months

• PDR/DME = Monthly

• EMR Note Generated, e-faxed to PCP


CDC Eye Exam

Medical record documentation for eye exams:

1. Member/Patient’s Name and DOB

2. Date of Service

3. Signature from the provider that performed the exam, whichmust include one of the following credentials:

• Optometrist- O.D.

• Ophthalmologist- M.D.

• Please ensure signature includes a notation of Ophthalmology as the provider’s specialty

4. Medical Record evidence showing one of the following:

• A retinal or dilated eye exam for 2018 with results

• Or a negative retinal or dilated eye exam in 2017 with results

• Or evidence of a bilateral or two unilateral enucleation any time in the members history


CDC Eye Exam

• Accepted Documentation of a Dilated or Retinal Eye Exam:

• Abbreviations - phrases indicating an exam was performed include the below: (this list is for reference, and is not exhaustive)

• Documentation provided must also state the results of the exam:

• Diabetic Eye Exam/Dilated Eye

Exam (DEE)

• Post. Chamber (P), Disc (D),

Macula (M), Vessel (V), Periphery

(P)• Dilated Fundus Exam (DEF)

• Diabetic Retinopathy (DR) • Negative/No Diabetic

Retinopathy

• Background Diabetic Retinopathy

(BDR)

• Non-Proliferative Diabetic

Retinopathy (NPDR)

• Proliferative Diabetic Retinopathy

(PDR)

• No Ocular Complications


CDC Eye Exam

Unacceptable Documentation of a Dilated Eye Exam:

• “Diabetes without Complications”


Diabetes Eye Exam Communication Form Comprehensive Diabetes Care Screening or Monitoring for Diabetic Retinal Disease Megan Wilson, HEDIS Program Manager Partnership HealthPlan of California | 4665 Business Center Drive, Fairfield, CA 94534 Phone: (866) 828-2302 | Fax: (707) 863-4314

Eye Care Specialist: In order to meet the annual documentation requirement for Healthcare Effectiveness Data and Information Set (HEDIS), please assist us in clarifying / obtaining this member’s most recent retinal exam findings. Please fax or mail this form along with exam notes to the contact listed above.

Please complete the sections below:

The following patient had a dilated or retinal examination for evaluation of diabetic retinopathy.

Patient Name Date of Birth:

CIN #: Date of Eye Exam:

Eye Examination Report

Retinal Exam Findings (Put an X for applicable findings) OD OS

No Diabetic Retinopathy (DR)

Non-proliferative DR: Mild Moderate Severe

Proliferative DR

Recommended follow-up in months

Additional comments:

Eye Care Specialist’s Signature:

Eye Care Specialist’s Name (Please print):

Ophthalmologist or Optometrist (Put an X by one) Date:

Retain a copy in Patient Record CDC-EE 05/18

Disclaimer: Health Services Advisory (HSAG) finds that this form completed by the provider along with exam notes in the member’s medical record would meet HEDIS criteria for acceptable documentation of a member’s most recent retinal exam results. As a stand-alone document the form would have to be included as part of the member’s medical record and reference that the eye exam was actually completed to meet HEDIS criteria for acceptable documentation.


HEDIS 2019 Timeline

Aug

Mar May

Jun

Jul

AprFeb

Week of Feb 11thPHC kicks off annual

HEDIS Audit

Primary Medical Record Retrieval &

Review

Secondary Medical Record

Retrieval

May 9th

Stop all Retrieval & Review

Final rates locked and reported to

DHCS

Medical Record Review Validation

Audit May 10th-15th

HEDIS 2019 Performance shared with

Provider Network


Eye Care Providers & PHC

• Contracted Providers • Participation in Partnership’s Quality Improvement and

Utilization Management Programs is required per contract. This includes participation in office reviews, chart and access audits, and focused reviews.

• VSP Providers• This request is covered by the Health Insurance Portability

and Accountability Act of 1996 (HIPAA), as amended, the Privacy Rule and state law.


Resources

• http://www.partnershiphp.org/Providers/Quality/Pages/HEDISLandingPage.aspx

• HEDIS 2018 Performance

• HEDIS FAQs

• Upcoming Events and Activities

• Measure definitions and documentation requirements

PHC’s HEDIS Website

NCQA Website

• http://www.ncqa.org/HEDISQualityMeasurement.aspx

http://www.partnershiphp.org/Providers/Quality/Pages/HEDISLandingPage.aspx

http://www.ncqa.org/HEDISQualityMeasurement.aspx


Contact Us

For all questions please contact the PHC HEDIS Team:

• Phone: (866) 828-2302

• Fax: (707) 863-4314

• Email: [email protected]

• Mail: Attn: QI HEDIS Team

Partnership HealthPlan of California

4665 Business Center Drive

Fairfield, CA 94534


Questions?

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