In this section, you’ll find:
• Ways to improve Star ratings by using health information
• Benefits of using CPT II codes
• Sample CPT II codes for Star measures
• Benefits of supplemental data sharing
• Frailty and advanced illness exclusion information and sample value set codes
• Health Information Exchange overview
Providing health information can improve HEDIS measure rates and the overall Star rating. Click here to see a list of HEDIS measures and details.
We monitor and aggregate HEDIS data for each of our customers based upon information that is received by providers. However, a portion of these HEDIS metrics can be difficult to calculate without relevant information from the services you provide to your patients. (Click here for HEDIS measure details.)
The exchange of this information is good for you and your patients. Our goal is to house the most real-time and accurate data possible so that we can share insights with you to guide your clinical best practices and preventive services for your patients at the appropriate time. By sending this information to us, your patient outreaches and interventions can be prioritized based on actual needs and not data inaccuracies. Additionally, providers who participate in value-based programs can receive financial incentives that reflect accurate data.
You can help us close gaps by submitting data through one of these methods.
Data that providers submit gives us the necessary information to close Star measure gaps, or ensure that a customer is compliant for certain Star measures for which they are eligible.
The most accurate and real-time source for submitted data is through claims submission with CPT Category II codes. This method is great for all providers to electronically submit their information on a completed claim form. In addition to the benefits of accuracy and timing, utilizing CPT II codes may positively affect provider incentive programs, such as P4Q. (CPT II code information can be found here.)
Supplemental data sharing is the exchange of data from the electronic health record backend information in a standardized file format that is submitted to us. This method is great for providers in full risk agreements, P4Q, or with a large Cigna Healthcare Medicare Advantage population. (For more information on supplemental data sharing, click here.)
Completing one of our approved 360 Comprehensive Assessment options is a great way for participating providers to send information. Our internal team members will use these approved templates to code gaps appropriately and use the data to close gaps in reporting. (Click here for 360 information.)
Healthcare Quality Data Capture module in the Arcadia platform, which allows you to enter medical record data you would like to see reflected in our Quality and Stars reporting. Reach out to your Provider Performance Enablement representative for more information on the process to get access.
In the event the first four data methods are not possible, please reach out to your Provider Performance Enablement representative to further discuss your specific situation and assess if there may other unique opportunities for collaboration with Cigna Healthcare Medicare Advantage.
Reduces administrative burden for providers by easily providing quality data on patients through claims.
Provides more accurate data, reducing the need for record abstraction and chart review.
Helps quickly identify and close gaps in care, and evaluate HEDIS performance improvements.
Relays important information regarding to health outcome measures.
Tracks patient screenings to help monitor ongoing care.
Two tips to help ensure proper documentation.
CPT Category II codes:
Are arranged by category and comprised of four numerals followed by the letter F.
May be submitted on claims with other applicable codes.
*CPT II codes are updated annually according to HEDIS specifications published by NCQA.
Click here for a list of CPT II codes to document CAHPS and HOS-related conversations.
*Both systolic and diastolic should be submitted for the same DOS in order to meet the Blood Pressure HEDIS measure.
**Both 1159F and 1160F must be submitted on the same claim in order to meet the Care For Older Adults Medication Review HEDIS® measure.
It’s happening more and more because payers and providers are working together.
What is supplemental clinical data?
This is data captured real time in medical records and other electronic data sources that you send to us. It supplements data we capture through traditional means, such as claims and encounters, and plays an important role in helping us to identify and report to you any gaps in care for your patients with Cigna Healthcare plans.
Ways to share supplemental clinical data
When applicable, we recommend billing CPTII codes to share clinical data. When that is not possible, the fastest and most efficient way to share this data is by providing us with direct access to your electronic health record (EHR) system. Some providers may elect to share data through Arcadia or the HEDIS-approved template highlighted below.
ArcadiaProviders use this population health tool and clinical data integration program to enhance data sharing with health plans, and to access relevant clinical data to help manage their patients more effectively. Arcadia offers:
− An advanced longitudinal record on patients.
− Transition-of-care insights, with timely alerts for patient admissions and discharges allowing for prompt follow up.
− Expansive EHR compatibility for a more efficient onboarding process.
HEDIS-certified softwareProviders can share supplemental clinical data with us via a proprietary template used to upload data into our HEDIS-certified software.
Benefits of sharing data
When you send supplemental clinical data to us, you may:
Improve quality measures through hybrid data capture that supports quality programs such as HEDIS, Star ratings, and the Partnership for Quality (P4Q) provider incentive program.
Close care gaps through integration of additional data.
Reduce administrative burden and improve operational processes through streamlined and automated chart retrieval.
Have more accurate, comprehensive, and consistent chronic-condition documentation and care-gap reporting.
How we use supplemental clinical data
We use clinical data to create reports that include patient-level information around coding and documentation opportunities and quality outcomes. The reports are refreshed regularly to include all available data from:
Approved claims at the time of the refresh.
Arcadia and the HEDIS supplemental file.
Documentations and coding resources
We offer a variety of education and resources to help providers submit accurate and complete coding. Visit MedicareProviders.Cigna.com > Provider Education > Documentation and Coding Resources.
For assistance submitting claims with all appropriate coding best practices, please contact your Provider Performance Enablement or Provider Education representative.
How to initiate supplemental data sharing
Contact your Provider Performance Enablement representative to determine which method aligns best with your current processes or EHR system.
Claim submission deadlines for a particular DOS are based on individual provider contracts.
Please see 2024 P4Q Attachment A, section 5.a for more information about claims period; section 5.e for more information about payment of earned quality incentive payments.
Click here for information on HEDIS Medical Record Review (MRR) project.
Click here for information on the Provider Enablement Stars Dashboard.
Overview
As Medicare beneficiaries age and potentially become more frail, the treatment goals established with their providers focus more on quality of life rather than prevention and detection of disease. In recognition of this, the National Committee for Quality Assurance (NCQA) has established exclusion guidelines for several HEDIS CMS Star Measures that allow for the removal of beneficiaries who are frail or have advanced illness.
The appropriate documentation and submission of the frailty and advanced illness CPT, HCPCS, or International Classification of Diseases, Tenth Revision (ICD-10) value set codes in the tables below will remove patients from the following measure denominators when submitted via claims in the measurement year.
Controlling High Blood Pressure (CBP) – 81 and older with frailty, or 66-80 with frailty and advanced illness
Osteoporosis Management in Women (OMW) – 81 and older with frailty, or 67-80 with frailty and advanced illness
Breast Cancer Screening (BCS) – 66 and older with frailty and advanced illness
Colorectal Cancer Screening (COL) – 66 and older with frailty and advanced illness
Statin Therapy for Patients with Cardiovascular Disease (SPC) – 66 and older with frailty and advanced illness
Hemoglobin A1c Control for Patients with Diabetes (HBD) – 66 and older with frailty and advanced illness
Eye Exam for Patients with Diabetes (EED) – 66 and older with frailty and advanced illness
Kidney Health Evaluation for Patients with Diabetes (KED) – 81 and older with frailty, or 66-80 with frailty and advanced illness
Health Information Exchanges (HIEs) are local standardized data repositories through which hospitals, health care providers, and pharmacists can electronically document, track, and share patient health data. They are a convenient means to ensure key medical data such as admissions, discharges, and information associated with a visit is complete, current, and easily accessible. HIEs also improve the speed, quality, safety, and cost of patient care (HealthIT.gov).
In addition to supporting patient care, HIEs can enable high performance on three Star rating measures. These measures require timely communication about patient admission and discharge so that documentation and outreach occur within the designated timeframe. The measures are:
Transitions of Care (TRC), which requires documentation of inpatient admission to the hospital, discharge from the hospital, patient engagement post-discharge, and medication reconciliation.
Follow-up after emergency department (ED) visit for people with multiple high-risk chronic conditions (FMC), which requires follow-up services within seven days of discharge.
Plan All-Cause Readmission (PCR), which encourages follow-up services to prevent readmission within 30 days of discharge
Benefits of an HIEParticipating in a local HIE can help providers:
Better track and securely share a patient’s complete medical history
Improve the completeness of patient records
Standardize data so that it can be easily integrated into a patient’s EHR
Provide easy access to a patient’s medical information
Prevent errors by ensuring that everyone involved in a patient’s care has access to the same information
Avoid readmissions and medication errors
Decrease duplicate or unnecessary testing
Accessing your local HIE
Contact your state’s HIE representative. A list of state contacts and exchange service providers is available on the HealthIT.gov website. The website also includes news and updates on state Health Information Exchange Programs.
Speak with exchange service providers in your state or region. Service providers may differ specifics, such as:
Economics and sustainability
Internal requirements
Technology
Risk and liabilities
Speak with your EHR vendor. Some vendors have incorporated the functionality of the HIE into their EHR. Things to consider:
HIE capabilities within the EHR
Privacy and security features
Form(s) of exchange that are supported
Costs of upgrading, maintenance, and monthly charges
Helpful resources
Regional and national admission and discharge information is updated in the CareAllies® enabled population health tool, Arcadia, in real time. You can access the recent admits and discharges report from the home page on a daily basis to conduct appropriate and timely follow up with patients who have had an event. If you are interested in gaining access to Arcadia or this report, please contact your Provider Performance Enablement representative.