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February 2015
Medicare Advantage Diagnosis Closure Incentive program continues in 2015
Address chronic conditions, past diagnoses
The Diagnosis Closure Incentive program is in effect this year for dates of service on or after Jan. 1, 2015.
As you conduct face-to-face, annual wellness visits with Blues Medicare Advantage patients, make sure you address every chronic condition or past diagnosis that still applies to the patient. Then document this information in the patient’s medical record following coding guidelines. Include all of the diagnoses in your claim submission.
Blue Cross Blue Shield of Michigan and Blue Care Network will continue the Medicare Advantage Diagnosis Closure Incentive program in 2015.
The incentive program again applies to Blues Medicare Advantage patients, including those with Blue Cross Medicare Plus Blue PPOSM, Medicare Plus Blue GroupSM PPO, BCN Advantage HMO-POSSM and BCN Advantage HMOSM coverage.
Diagnosis Closure Incentive program
The incentive program rewards participating primary care doctors for having annual, face-to-face visits with Blues Medicare Advantage patients to evaluate, document and code diagnoses according to standards set by the Centers for Medicare & Medicaid Services. Doctors will receive a financial incentive for closing diagnosis gaps identified by the Blues.
A “gap” is a suspected or past condition that hasn’t been documented and coded in the current year.
The Diagnosis Evaluation Panel on MAPPO Health e-BlueSM lists patients who are suspected of having a condition based on:
- Pharmacy claims
- Medical claims
- Other supplemental data sources
- Prior-year diagnoses
But the diagnoses for patients listed on the Diagnosis Evaluation panel haven’t been submitted to the Blues in the current year. The report will be refreshed monthly so doctors can track their progress in closing these identified diagnosis gaps.
The Blues will pay doctors $100 for each Medicare Advantage member with one or more gaps identified between Jan. 1, 2015, and Sept. 30, 2015, and for whom all gaps are closed during a face-to-face encounter by Dec. 31, 2015.
An identified gap can be closed following a face-to-face visit with the patient in 2015. During this visit, the doctor should manage, evaluate, assess or treat the condition, and the diagnosis should be documented in the patient’s medical record following CMS guidelines. The gap can then be closed through one of the following methods:
- Confirm the diagnosis code:
- By submitting a claim with the diagnosis code
- Through Health e-Blue
- By submitting a paper Member Diagnosis Evaluation and Treatment Opportunities Report (for those without access to Health e-Blue)
- By submitting a patient medical record
- Notify the Blues that the patient does not have the suspected condition:
- Through Health e-Blue
- By submitting a paper Member Diagnosis Evaluation and Treatment Opportunities Report (for those without access to Health e-Blue)
Note that a gap should not be closed solely for the reason that you are not actively treating the condition. A diagnosis gap should only be closed if you have conducted an office visit, addressed the condition and determined that the patient no longer has the condition or the suspected condition does not exist.
More information about this incentive program will be posted on Health e-Blue for Medicare Advantage primary care doctors in the first quarter 2015. If you don’t have access to Health e-Blue, sign up today on bcbsm.com/provider. Contact your provider consultant if you need assistance.
web-DENIS member care alerts
When checking patient eligibility and benefits on web-DENIS, be sure to check your member care alerts, which have been updated to include 2015 patient gaps in care.
These alerts are color-coded to help you identify patient needs quickly, and they display a printable list of diagnosis gaps and treatment opportunities for patients.
2014 incentive payment
If you participated in the 2014 Diagnosis Closure Incentive program, your incentive payment will be mailed to you by the end of the third quarter.
Training available
The Blues can provide training to doctors 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.
Ask your provider consultant for a set of tip cards for your office called Documentation and Coding Tips for Professional Offices. The tip cards are also available electronically on web-DENIS. From the web-DENIS home page:
- Click on BCBSM Provider Publications and Resources.
- Click on Newsletters and Resources.
- Click on Patient Care Reporting.
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