New Medicare Advantage Diagnosis Gap Closure incentive program for primary care physicians for 2013
Replaces Physician Assessment Form reimbursement

Blue Cross Blue Shield of Michigan and Blue Care Network are pleased to announce a new primary care physician Medicare Advantage Diagnosis Gap Closure incentive program in 2013. The new incentive applies to Blues Medicare Advantage patients, including those with BCN Advantage HMO-POS^SM, BCN Advantage HMO Focus^SM and BCBSM Medicare Plus Blue PPO^SM coverage.

The new Diagnosis Gap Closure incentive program replaces reimbursement for completion of the Physician Assessment Form effective for dates of service Jan. 1, 2013, or later.

Here’s how it works
The Diagnosis Gap Closure incentive rewards physicians for having annual face-to-face visits with Blues Medicare Advantage patients during which diagnoses are evaluated, documented and coded according to standards set by the Centers for Medicare & Medicaid Services. Physicians will receive a financial incentive for closing diagnosis code gaps identified by the Blues.

Primary care physicians will be able to view a report of their Medicare Advantage patients who have diagnosis code gaps on Health e-Blue^SM in the first quarter of 2013. The new Medicare Diagnosis Evaluation Form on Health e-Blue will list Blues Medicare Advantage patients who are suspected of having a condition based on pharmacy claims, medical claims, other supplemental data sources or prior year diagnoses, but the diagnosis has not been submitted to the Blues yet in the current year on a claim, through Health e-Blue, on an electronic medical record or a paper version of the Diagnosis Evaluation Form.

A suspected or historic condition that has not been accurately documented and coded in the current year is considered a “gap”. Medicare Advantage patients with one or more gaps will be identified on the primary care physician’s Health e-Blue Diagnosis Evaluation Form.

The report will be refreshed monthly so physicians can track their progress in closing these identified diagnosis code gaps. The Blues will pay physicians $100 for each Medicare Advantage member with one or more gaps identified between January and October 10, 2013, for whom all gaps are closed during a face-to-face encounter by Dec. 31, 2013 and reported to the Blues by Jan. 31, 2014 following CMS guidelines.

An identified gap can only be closed following a face-to-face visit with the patient in 2013 during which the diagnosis is documented in the patient’s medical record following CMS guidelines. Then the gap must be closed through one of the following methods:

• Confirming the diagnosis code
  • By submitting a claim with the diagnosis code
  • Through Health e-Blue
  • By submitting a paper Diagnosis Evaluation Form*
  • Through an EMR interface (available after May 2013)
• Notifying the Blues that the patient does not have the suspected condition
  • Through Health e-Blue
  • By submitting a paper Diagnosis Evaluation Form*
  • Sending a delete record on an EMR file (available after May 2013)

Gaps that are closed by Inovalon^™, formerly MedAssurant, will not result in an incentive payment.

Tip: As you conduct face-to-face annual wellness visits with Blues Medicare patients, make sure you address every chronic or previously diagnosed condition or past diagnosis that is still relevant to the patient, including transplant or amputation status. Then document this in the patient’s medical record following coding guidelines and include all of the diagnoses in your claim submission.

More information about this new incentive program will be mailed to Blues Medicare Advantage primary care physicians in early 2013. If you do not have access to Health e-Blue, sign up today on bcbsm.com/provider. Please contact your provider consultant for assistance.

Learn more about documentation, coding and closing gaps

The Blues have staff available who can provide training to physicians and their office staff on proper documentation and coding guidelines and the importance of closing gaps for Medicare Advantage patients. Contact your provider consultant for more information.

If you would like a Blues speaker to address a large provider group on this topic, please contact Laurie Latvis at LLatvis@bcbsm.com.

**The new paper Diagnosis Evaluation Form will be available in January on web-DENIS in BCBSM Provider Publications and Resources. Click on Newsletters & Resources and then click on Medicare Advantage Resources.