Ingenix InSite User Group

1. Ingenix InSite User Group July 13, 2010 Approval Code: IN180

2. Ingenix InSite User Group: Welcome Administrative Reminders: • This call is hosted in a listen only mode for participants until our Q&A segment. • Questions you may want to ask prior to the Q&A segment can be typed in our chat panel for the host to address • Please keep your phones on mute during Q&A. • The webex login password for this call is ‘insite’. • When logging into the webex please enter in your first and last name. • The user group presentation materials will be sent with the meeting minutes. • Ingenix InSite User Group Questions or Product Enhancement requests? Email ingenix.insite@ingenix.com. • Ingenix InSite Website Questions? Call or email the Ingenix Helpdesk 1-866-818-7503 or client.support@ingenix.com.

3. Ingenix InSite User Group: Agenda • 10:00 AM – 10:05 AM Welcome & InSite Operations Announcements • 10:05 AM – 10:10 AM Submission Timelines • 10:10 AM – 10:30 AM VTE including DVT & PE • 10:30 AM – 10:55 AM Provider to Group Validation FAQ’s • 10:55 AM – 11:00 AM Q & A

4. InSite Operations Announcements • Data Refresh Update • InSite data was refreshed July 11th • Next data refresh targeting August 9th • July 30th 2010 – New InSite Release • Prevalence Report modification for filtering by health plan • Freeze column headers on reports, searches & custom lists • New Superbills for Nephrology & Pediatrics • July Ingenix Insider • Updated ICD-10 Link • InSite Compatibility with: • Internet Explorer 7.0 • Internet Explorer 8.0

5. Sweeps Updates Presented by: Pam Holt Regional Manager Market Consultation Southern California

6. 2010 September Sweep Information DOS Included: July 1, 2009 – June 30, 2010 For CMS Payment Period: January 2011 – June 2011 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * CMS Published Sweep Date: • September 3, 2010 = CMS published Sweep Date • Historically the Sept Sweep has taken place 2 weeks from the published sweep date, which would be September 17

7. 2010 September Sweep Information Health Net Deadlines: • August 20 = DDD’s deadline to Health Net • August 12 = Group’s deadline to DDD • August 20 = Group’s deadline if submitting directly to James Van Dyne • Any data submitted after these dates will be processed and submitted to CMS, but the later the data is submitted, the greater the risk of not making it into the September Sweep • Any 2010 DOS data not making it into the September Sweep, if accepted by CMS, will become part of the March 2011 Sweep

8. 2010 September Sweep Information SecureHorizons Deadlines: • July 30, 2010 = Group’s deadline: • to submit data to clearing house, allowing time for any rejected data to be corrected and resubmitted • August 13, 2010 = Group’s deadline for: • Electronic submission to CH (may not have time to handle rejects) • ASM via PacifiCare Provider Portal • Any data submitted after these dates will be processed and submitted to CMS, but the later the data is submitted, the greater the risk of not making it into the September Sweep • Any 2010 DOS data not making it into the September Sweep, if accepted by CMS, will become part of the March 2011 Sweep

9. VTE including DVT & PE Prepared for Ingenix InSite by: Linda R. Farrington, CPC, CPC-I Sr. Provider Training & Development Consultant Ingenix Clinical Assessment Solutions

10. VTE Defined • Venous thromboembolism(VTE) is a disease that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). • The process by which blood clots occur and travel through the veins is known as venous thromboembolism (VTE), the collective term for DVT and PE. http://www.patienthealthinternational.com/venous-thromboembolism/

11. DVT Defined • Deep vein thrombosis (DVT) is the formation of a blood clot in one of the deep veins within the body, such as in the leg or pelvis. This kind of thrombosis can occur after surgery and may cause redness, pain and swelling. http://www.patienthealthinternational.com/venous-thromboembolism/

12. PE Defined • Pulmonary embolism (PE) is a serious condition in which the arteries leading from the heart to the lungs becomes blocked. It can occur when a blood clot breaks away from its original location and travels to the lungs. Symptoms may include sharp chest pain, shortness of breath and coughing up blood. http://www.patienthealthinternational.com/venous-thromboembolism/

13. Pulmonary Embolism Codes - Acute • Old Code for Pulmonary Embolism revised: • Look-up in Index • Embolism, pulmonary (acute) (artery) (vein) 415.19 • Index was revised for 2010, added acute • 415.19 Acute pulmonary heart disease, pulmonary embolism and infarction, other • This subcategory (415.1) specifically excludes: • Chronic pulmonary embolism (416.2) • Personal history of pulmonary embolism (V12.51)

14. Pulmonary Embolism Codes - Chronic • New Chronic Code for 2010 effective 10012009: • Chronic pulmonary embolism – 416.2 (HCC 104) • Use additional code, if applicable, for associated long-term use of anticoagulants (V58.61)

15. New Chronic Codes for 2010 effective 10012009: • Chronic venous embolism and thrombosis of: • unspecified deep vessels of lower extremity453.50 (HCC 105) • deep vessels of proximal lower extremity453.51 (HCC 105) • deep vessels of distal lower extremity453.52 (HCC 105) • superficial veins of upper extremity 453.71 (no HCC) • deep veins of upper extremity453.72 (HCC 105) • upper extremity unspecified 453.73 (no HCC) • axillary veins453.74 (HCC 105) • subclavian veins453.75 (HCC 105) • internal jugular veins453.76 (HCC 105) • other thoracic veins453.77 (HCC 105) • other specified veins 453.79 (no HCC)

16. New Acute Codes for 2010 effective 10012009: • Acute venous embolism and thrombosis of: • superficial veins of upper extremity 453.81 (no HCC) • deep veins of upper extremity453.82 (HCC 105) • upper extremity, unspecified 453.83 (no HCC) • axillary veins453.84 (HCC 105) • subclavian veins453.85 (HCC 105) • internal jugular veins453.86 (HCC 105) • other thoracic veins453.87 (HCC 105) • other specified veins 453.89 (no HCC)

17. New Code not specified as acute/chronic eff. 10012009: • 453.6 Venous embolism and thrombosis of superficial vessels of lower extremity • Saphenous vein (greater) (lesser)

18. Deleted & Revised Codes for 2010 effective 10012009: • Deleted: • 453.8 Other venous embolism and thrombosis of other specified veins • Revised: • 453.2 (HCC 105) Other venous embolism and thrombosis of inferior vena cava • 453.40 (HCC 105) Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity (DVT, NOS) • 453.41 (HCC 105) Acute venous embolism and thrombosis of deep vessels of proximal lower extremity • 453.42 (HCC 105) Acute venous embolism and thrombosis of deep vessels of distal lower extremity

19. Personal History Codes • Personal history of: • Embolism (pulmonary) V12.51 • Thrombosis V12.51 • If the provider documents “History of PE” it is coded as V12.51. • If the provider documents “History of DVT” it is coded as V12.51. • V12.51 Personal history of diseases of circulatory system, venous thrombosis and embolism

20. Long-term (current) use of anticoagulant • Long-term (current) use of • Anticoagulants V58.61 • Antiplatelets/antithrombotics V58.63 • Aspirin V58.66 • Under each of the chronic subcategories, ICD-9-CM instructs: • Use additional code, if applicable, for associated long-term (current) use of anticoagulants (V58.61) • These codes do not risk adjust. • It is important to report the condition for which patient is being treated. • These codes report the long-term treatment only.

21. Complication Code for Thrombosis • Thrombosis, thrombotic (marantic) (multiple) (progressive) (vein) (vessel) • due to (presence of) any device, implant, or graft classifiable to 996.0-996.5 • see Complications, due to (presence of) any device, implant, or graft classified to 996.0-996.5 NEC 996.70 • 996.70 (HCC 164) Other complications of internal (biological) (synthetic) prosthetic device, implant, and graft • Including thrombus • Use additional code to identify the complication

22. Complication Code for ThrombosisDocumentation & Coding Tips • If the documentation states that the patient has a thrombus due to a device, implant, or graft, it is important to report the complication code. • When documenting a complication: • Document the specific complication. • Document the device, implant or graft, if applicable.

23. DVT & Hypercoagulable State • Question: • We've heard that a patient with deep venous thrombosis can automatically also be assigned a code for hypercoagulable state. Is this correct? • Answer: • No, the presence of a deep venous thrombosis (DVT) does not imply that a hypercoagulable state exists. DVT can occur without a hypercoagulable state, which is why the documentation needs to be specific. Code assignment is based on provider documentation. A hypercoagulable state is a condition in which there is an increased tendency for blood clotting and it may be due to a number of conditions. While the most common clinical manifestation of an underlying hypercoagulable state is lower deep venous thrombosis with or without pulmonary embolism, codes 289.81, Primary hypercoagulable state, and 289.82, Secondary hypercoagulable state, should not be assigned without provider documentation when only deep venous thrombosis is documented. AHA Coding Clinic, 2008, 3rd Qtr

24. DVT & Inflammation (Thrombophlebitis) • If the documentation states that the thrombus is not associated with inflammation, assign the appropriate code from rubric 453. • If the signs and symptoms associated with inflammation (swelling, erythema, pain, induration) are documented, query the physician as to whether the condition is thrombophlebitis and, if it is, assign a code from rubric 451 instead. • Report code from rubric 451 for thrombosis with thrombophlebitis. Ingenix Coders’ Desk Reference for Diagnoses 2010 pg. 411

25. Acute vs. Chronic • Previously, patients with chronic thromboembolic disease were erroneously reported as having an “active” or acute thrombosis when the patient was actually maintained on anticoagulant therapy for a chronic condition. • Codes differentiate between acute (453.81-453.89) and chronic (453.50-453.52, 453.6, 453.71-453.79) disease and identify specific anatomic sites previously classified to 453.8. • No official definition exists for the terms “chronic” and “acute.” • In general, initial episode of care would indicate the acute phase, while “subsequent episode of care” would indicate the chronic phase. Ingenix Coders’ Desk Reference for Diagnoses 2010 pg. 411

26. Clinical Scenario #1 • Patient presents with deep venous thrombosis and is started on enoxaparin and warfarin therapy. • Look-up in the Index of ICD-9-CM is: • Thrombosis • Vein • Deep 453.40

27. Clinical Scenario #2 • Patient is continued indefinitely on warfarin after a second unprovoked episode of pulmonary embolism. • Look-up in the Index of ICD-9-CM is: • Embolism • Pulmonary (acute) (artery) (vein) • Chronic 416.2 • Long-term (current) • Anticoagulants V58.61

28. Ingenix would like to … Thank You for your Participation!

29. Provider to Group Validation FAQ’s Presented by: Patrice Buchana / Jerry Gauchat Regional Director Market Consultation / InSite Business Analyst

30. InSite Provider to Group Mapping - Purpose The purpose of provider to group mapping is to protect member’s health information. The benefits of this process include: • Action is taken within Ingenix InSite to remove access to PHI data when mappings are incorrect • Ability for Groups to manage their own mappings within Ingenix InSite for access to the appropriate provider and member data • Helps the Groups, Health Plan and Ingenix meet the minimum necessary rules under HIPAA and the American Reinvestment and Recovery Act.

31. InSite Provider to Group Mapping - Process • All users for a group are able to perform provider to group mapping validation • Steps to validate providers: • Access the Provider Validation tab • Action is required on each provider record listed • Associate a provider to the group • Disassociate a provider to the group

32. InSite Provider to Group Mapping - Monthly Steps • New provider and member data will not be available until the group validates the provider as being associated with the group • Status = Suppressed (New)

33. InSite Provider to Group Mapping - General Information • TIPS & REMINDERS: • Users can view all providers and their statuses by clicking “View All Providers” link • The default view of the Provider Validation screen (no filters selected) displays the providers which still require validation. If there are no providers left on the screen, the validation is done, the provider to be validated count should be 0 (zero) and the Complete Validation button should be available. • Summary level reporting – aggregated reports will include the suppressed providers’ data until they no longer appear within the data supplied by the health plans. • Monthly – Any providers identified by InSite as newly added to the group within the monthly data refresh will be suppressed and would need to be validated as Associated prior to their information being available in the reports for the group. • The Provider validation tab will be red when immediate action is needed. If the tab name is in red font, there are either new providers to validate that were identified in the Monthly Data Load or there are 15 days or less to complete validation. • The validation status for the provider may be updated at any time if you are aware a change needs to be made outside of the validation period.

34. InSite Provider to Group Mapping FAQ’s • Question 1: • Will everyone in the group get the email notifications when a validation is coming or about to expire?    • Answer 1: • Yes, all users will receive email notifications.  • Question 2: • Why is the same provider listed multiple times? • Answer 2: • The same provider is listed multiple times because the provider is potentially listed for each health plan he or she represents in the application (i.e. If John Doe has members for both Health Plan A and Health Plan B he will be listed twice but if he only has members for Health Plan B he will only be listed once). Health plans at times provide multiple IDs for providers that can reflect an ID for each provider location or group assignment. • All records should be approved if the same provider is listed multiple times.  • Question 3: • What should be done if the NPI or tax id for a provider is missing or incorrect? • Answer 3: • If provider groups determine incorrect NPI or tax id information is displaying for a provider, the data issue should be reported to your health plans.

35. InSite Provider to Group Mapping FAQ’s • Question 4: • Where can I find training materials on the Provider to Group Validation Process?     • Answer 4: • The InSite help link at the top right of the browser window will open a separate window with all information on InSite. There is a list of book icons on the left. Select the Provider to group Validation book to obtain information regarding the process.

36. InSite Provider to Group Mapping FAQ’s • Question 5: • When do the changes take effect when I select Associate and Disassociate? • Answer 5: • The reports reflect the action taken during validation immediately. The providers and member data tied to that provider will be viewable effective immediately for Associated providers and will be suppressed immediately following the Disassociate button. Users do not need to log out and log back in to view the associate/disassociate action. • Question 6: • What are possible reasons I could be getting a notification daily? • Answer 6: • InSite automatically notifies groups at the beginning of each Provider Validation period. If a group is completing their validation in one day and the group is hitting the complete validation button, then the group would be receiving the notification the next day stating their new validation cycle has begun.

37. InSite Provider to Group Mapping FAQ’s • Question 7: • I performed the provider validation cycle, however I am still receiving notification that my validation has not been completed? • Answer 7: • Groups need to click the “Complete Validation” button for the system to recognize the validation has been completed. • Question 8: • My office uses Internet Explorer 8.0 and we have had issues accessing certain features within InSite including completing the Provider Group Validation process in a timely manner. Will InSite be compatible with IE 8.0 soon? • Answer 8: • Ingenix is currently testing the compatibility of InSite with current versions of multiple browsers including Internet Explorer 8.0 and anticipate making InSite compatible with IE 8.0 in the upcoming release.

38. InSite Provider to Group Mapping FAQ’s • Question 9: • I was told that this Provider Validation process was important from a Protected Health Information (PHI) standpoint. Why is it no longer a requirement for retaining access to reports? • Answer 9: • Safeguarding PHI is always of critical importance. However, we have examined and are exploring other ways to achieve this outside of the current Group to Provider Validation process. • Question 10: • Is the Group to Provider Validation process that was required a couple of weeks ago now considered optional? • Answer 10: • We still encourage all groups to complete the Provider to Group Validation process by disassociating any physicians that are not a part of the group. However, what has changed is that access to InSite will be maintained even if this process has not been completed. Any new providers will require validation in order to show up in InSite reports. • Question 11: • Can we expect other changes to the Group to Provider Validation process? • Answer 11:   • We are always evaluating our policies and procedures. Should any other changes occur in the future, we will provide InSite users prior notice with an explanation of any changes.

39. InSite Provider to Group Mapping FAQ’s • Question 12: • After a monthly data refresh, why are my new providers not showing up in my InSite reports? Answer 12: • Any providers identified by InSite as newly added to the group within the monthly data refresh will be suppressed and would need to be validated as Associated prior to their information being available in the reports for the group.

40. Question and Answer Approved: IN071

41. InSite Provider to Group Mapping - General Information • Status Definitions • Suppressed–The Provider will not be visible in any reports; nor any of the members for that Provider • Suppressed (New) – The Provider was identified as ‘New’, meaning that they were not in the previous data load but came in on the present data load. The data for the Provider and members for that provider will not be visible until validation is completed. • Not Suppressed – The Provider has been validated as belonging to the group. • Filter Definitions • Validation Required – Choose this filter to see only those records remaining to be validated. • Newly Added – Choose this filter to see the groups’ newly added Providers identified in the Data Refresh. • Suppressed – Choose this filter to see all the Providers that have a Status of Suppressed. • Not Suppressed – Choose this filter to see all the Providers that have a Status of Not Suppressed.