CASE MIX UPDATES WEBINAR
CASE MIX UPDATES WEBINAR
June 6, 2019
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SUBMISSION GUIDE HIGHLIGHTS
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CHANGES & REVISIONS
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HOSPITAL INPATIENT
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CHANGES & REVISIONS
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HOSPITAL EMERGENCY
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CHANGES & REVISIONS
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HOSPITAL OUTPATIENT OBSERVATION
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QUESTIONS & COMMENTS
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Kathy Hines, Senior Director of Partner Operations and Data Compliance
Kathy.Hines@MassMail.State.MA.US
Catherine Houston, Manager – Hospital Data Compliance
Catherine.Houston2@MassMail.State.MA.US
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Linda Stiller, Senior Health Care Data Liaison
Linda.Stiller@MassMail.State.MA.US
Hadish Gebremedhin, Health Care Data Liaison
Hadish.Gebremedhin@MassMail.State.MA.US
Learn about key changes in the submission guide highlights and hospital inpatient discharge data, including new fields, file types, and streamlined edits. Explore the agenda for the webinar and get insights into upcoming timelines and verification reports. Understand the requirements for hospital inpatient discharge records and the significance of health plan member/subscriber flags.
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Presentation Transcript
CASE MIX UPDATES WEBINAR June 6, 2019
Agenda 2:00 Welcome 2:05 2:15 FY20 Submission Guide Highlights Walk Through of Proposed Changes 2:40 Timeline / Next Steps 2:45 Verification Reports/Potential Survey 2:55 Questions & Comments
Submission Guide Change Highlights Key Changes: New Fields File Types Health Plan Member/Subscriber Flag All Payer Type Additional diagnosis codes Additional CPT codes ED/OOD only OOD Only OOD Only Key Changes: Field Updates File Types HIDD/OOD ED Boarding Fields moved to B category Diagnosis/External Cause/Procedure Code edits streamlined Other assorted field/edit updates All All
CHANGES & REVISIONS FOR HOSPITAL INPATIENT
Hospital Inpatient Discharge Data New - Update Record Type Fields Description of requirement Remove 'NOTE' edit on the primary/secondary type and source of payment agreement Primary/Secondary Type/Source of Payment 20 U Require ID for MassHealth/HSN payer ONLY (not MCO/ACO) 20 Medicaid/MassHealth ID U 20 Patient Last Name U Change to required. 20 Patient First Name U Change to required. Health Plan Member/Subscriber Flag 25 N Must be present. Principal External Cause of Injury Code/ ICD Indicator Number of Hours in ED/ED Registration Date and Time/ ED Discharge Date and Time 45 U Streamline Edits; Remove ICD9 45 U Update error category to a 'B' 50 Assoc. Diagnosis Code I - XIV U Streamline Edits; Remove ICD9
Hospital Inpatient Discharge Data Health Plan Member/Subscriber Flag Valid Entries Definition 1 Health Plan Member ID (RT25 Field 19) is the Member ID 2 Health Plan Member ID (RT25 Field 19) is the Subscriber ID It is unknown whether the Health Plan Member ID is for the subscriber 3 or member
Hospital Inpatient Discharge Data Field Name Principal External Edit Specifications Must be present if principal diagnosis is an ICD-10-CM S-code (S00- S99), Cause Code May be present if principal diagnosis is an ICD-10-CM T-code (T00-T88), If present, must be a valid ICD-10-CM external cause code (V00-Y89). Additional (V00-Y89) and supplemental (Y90-Y99) ICD external cause codes shall be recorded in associated diagnosis fields. Field Name Assoc. Diagnosis Edit Specifications Only permitted if prior diagnosis is entered Code l Must be valid ICD code in diagnosis file Sex of patient must agree with diagnosis code for sex specific diagnosis May be an ICD external cause code (V00-Y99). Must agree with ICD Indicator
CHANGES & REVISIONS FOR HOSPITAL EMERGENCY
Hospital Emergency Department Data New - Update Record Type Fields Description of requirement Remove 'NOTE' edit on the primary/secondary type and source of payment agreement Require ID for MassHealth/HSN payer ONLY (not MCO/ACO) Primary/Secondary Type/Source of Payment 20 U 20 Medicaid/MassHealth ID U 20 Payer Type Code N See next slide Principal External Cause of Injury Code/ ICD Indicator/ Procedure Code 20 U Streamline Edits; Remove ICD9 20 Stated Reason for Visit Health Plan Member/Subscriber Flag U Must be NULL/blank due to high risk of PHI. 25 N Must be present. 50 Associated Diagnosis Code 1 - 15 U Streamline Edits; Remove ICD9 50 Patient Last Name U Change to required. 50 Patient First Name U Change to required.
Hospital Emergency Department Data Field Name Primary/Secondary Edit Specifications Must be present. Payer Type Code Must be valid as specified in Outpatient Emergency Department Visit Data Code Tables Section ll. If Medicaid is one of two payers, Medicaid must be coded as the secondary type and source of payment unless Free Care is the secondary type and source of payment.
Hospital Emergency Department Data PAYER TYPE ABBREVIATION 1 SP 2 WOR 3 MCR MCR-MC 4 MCD MCD-MC 5 GOV 6 BCBS BCBS-MC 7 COM COM-MC 8 HMO 9 FC 0 OTH * PAYER TYPE CODE * PAYER TYPE DEFINITION Self Pay Worker's Compensation Medicare Medicare Managed Care Medicaid Medicaid Managed Care Other Government Payment Blue Cross Blue Cross Managed Care Commercial Insurance Commercial Managed Care HMO Free Care Other Non-Managed Care Plans F B C D E PPO PPO and Other Managed Care Plans Not Classified Elsewhere H J K T N Q Z HSN POS EPO AI None CommCare DEN Health Safety Net Point-of-Service Plan Exclusive Provider Organization Auto Insurance None (Valid only for Secondary Payer) Commonwealth Care/ConnectorCare Plans Dental Plans
CHANGES & REVISIONS FOR HOSPITAL OUTPATIENT OBSERVATION
Hospital Outpatient Observation Data New - Update Field No. Fields Description of requirement Require ID for MassHealth/HSN payer ONLY (not MCO/ACO) 7 Medicaid/MassHealth ID U 103 Payer Type Code N See next slide Primary/Secondary Type/Source of Payment Remove 'NOTE' edit on the primary/secondary type and source of payment agreement 21-22 U ICD Indicator/ Principal External Cause of Injury Code/ Assoc_DX1 Assoc_DX15 Streamline Edits; Remove ICD9; Add 5 additional diagnosis code fields Change to May be present when Associated Diagnosis Code is present. 28-32; 72-78 U 62-68; 79-83 Condition Present on Observation U 85 Patient Last Name U Change to required. 86 Patient First Name Number of Hours in ED/ED Registration Date and Time/ ED Discharge Date and Time U Change to required. 87-91 U Update error category to a 'B' 92 Health Plan Member/Subscriber Flag Assoc_DX11- Assoc_DX15; CPT6 CPT10 N Must be present. Add 5 additional associated diagnosis codes; Add 5 additional CPT codes 93-102 N
Hospital Outpatient Observation Data Field Name Primary/Secondary Edit Specifications Must be present. Payer Type Code Must be valid as specified in Outpatient Observation Data Code Tables. If Medicaid is one of two payers, Medicaid must be coded as the secondary type and source of payment unless Free Care is the secondary type and source of payment.
Submission Guides Will Be Published to CHIA Website http://www.chiamass.gov/hospital-data-specification-manuals/
Timeline / Next Steps: FY20 Case Mix Intake Process Draft Timeline July 5, 2019 Provider Comment Period Ends July 2019 Administrative Bulletin and Guides Adopted July December 2019 CHIA and Providers Update Systems January 2020 Provider Testing Period March 16, 2020 Quarter 1 Submission
Follow-up Contacts Kathy Hines, Senior Director of Partner Operations and Data Compliance Kathy.Hines@MassMail.State.MA.US Catherine Houston, Manager Hospital Data Compliance Catherine.Houston2@MassMail.State.MA.US Hospital Liaisons: Linda Stiller, Senior Health Care Data Liaison Linda.Stiller@MassMail.State.MA.US Hadish Gebremedhin, Health Care Data Liaison Hadish.Gebremedhin@MassMail.State.MA.US
